Save Swine Flu Drugs for Younger Patients, Study Urges

29 july 2009-- Antiviral drug treatment of swine flu may be wasted on the elderly and should be reserved for young people, suggest researchers who created a model of the effect of antiviral treatment on the spread of the H1N1 virus.

If the current swine flu pandemic behaves like the 1918 flu, antiviral drugs would not significantly reduce death rates among people older than 65 and, in fact, might cause the H1N1 virus to develop increased drug resistance, according to Stefano Merler, of the Bruno Kessler Foundation in Italy, and his colleagues.

Their report appears online in BMC Infectious Diseases.

"Although it is too early to confidently predict some important features of the ongoing influenza pandemic, the use of antivirals is confirmed to be the most effective single intervention, in the absence of vaccines," Merler said in a news release from the journal's publisher. "It requires, however, a very large stockpile of antiviral drugs. Our work demonstrates that, even in countries where the antiviral stockpile is not sufficient to treat 25 percent of the population, the minimum level suggested by [the World Health Organization], it is possible to reduce morbidity and excess mortality by prioritizing the use of antivirals by age."

"Although a policy of age-specific prioritization of antiviral use will be controversial ethically, it may be the most efficient use of stockpiled therapies," he said. "This is of particular importance for countries where the amount of drug stockpiled is well below the WHO's suggested level."

The researchers concluded that developing early estimates of the impact of the swine flu pandemic and of age-specific death rates could prove important in optimizing the use of antiviral drugs during the pandemic.

More information

The U.S. Centers for Disease Control and Prevention has more about swine flu.

Elderly may have greater swine flu immunity: US

WASHINGTON , 23 may 2009– Older people may have some kind of immunity to swine flu, US health officials said Thursday, as the number of confirmed and suspected cases of H1N1 virus rose again around the country.

A study by the US Centers for Disease Control and Prevention (CDC) found that more than 64 percent of US infections have occurred among patients between the ages of five and 24, with just one percent of flu victims aged 65 or older.

One possible explanation is that "older adults might have been in contact a long time ago with a virus related to the one that we see now," said Anne Schuchat, interim deputy director for science and public health programs at the US Centers for Disease Control and Prevention.

"Adults might have some degree of pre-existing ... antibodies to the H1N1 virus, especially older adults over 60 or 65," she added.

"The presence of pre-existing antibodies may be due to previous exposure to (influenza) infection or vaccination."

Health authorities around the world have been surprised that with the number of cases of swine flu now topping 11,000, with 85 deaths, many of those infected have been younger people.

The CDC's study suggests children and teens may be particularly vulnerable to contracting the disease -- a worrying prospect as officials brace for the possible return in a few months' time of a more virulent strain of the H1N1 virus.

Schuchat added the flu outbreak was still "far from over" in the United States, where the tally of confirmed or probable US cases is now 5,764.

"The virus continues to circulate in the US," Schuchat said, adding there have been "localized outbreaks" in various states.

US health officials also remain concerned at delays in beginning production of a vaccine that could prove effective against swine flu.

This is especially urgent since the current batch of season flu vaccine does not provide protection against the H1N1 virus.

"We remain hopeful that we'll have vaccine viruses to send to manufacturers by the end of May," the CDC official said.

But Schuchat added that there are "many steps involved, and it will still be several months before a vaccine against this new virus will be available."

Schuchat offered a scrap of upbeat news, noting that flu-related visits to doctors and hospitals were on the wane across the United States, in what she considers a "good sign."

Pandemic warning system keys on 'human factors'

WEST LAFAYETTE, Ind., 14 may 2009 - Researchers are proposing a new system that would warn of an impending pandemic before the first case of disease emerged in a given population by detecting subtle signals in human behavior.

"The goal is a public information and awareness system for pandemic with the same level of credibility, timeliness and visibility as storm-warning icons presented on television screens," said Barrett Caldwell, a Purdue University associate professor of industrial engineering.

The system works by monitoring "event phases" of human behavior leading up to a pandemic, such as an increase in people purchasing flu-related medications or "foraging" on the Internet for certain types of information related to the flu.

Understanding these phases might be a way to overcome a fundamental hurdle in controlling pandemic: Conventional approaches require public-health officials to know when certain events leading to pandemic begin, Caldwell said.

"The problem with this requirement is that by the time you know an event has happened, it's often too late to do much about it," he said.

Caldwell and former Purdue industrial engineering doctoral student Sandra K. Garrett have proposed a new approach to warn the public of an impending pandemic.

"If you can recognize the triggers, the signals suggesting an event is likely to occur, you can start responding to it, gathering resources, preparing and mobilizing people," said Garrett, an assistant professor of industrial engineering at Clemson University. "Our basic research idea could be used for any pandemic, or even other types of disasters."

Garrett and Caldwell detailed the findings in a paper that will be presented June 2 at the Industrial Engineering Research Conference in Miami.

The paper shows how pre-pandemic events are separated into four categories of "human factors," or social behavior: a period during which it is first possible to detect signals of an emerging pandemic; a time when it is possible to begin early efforts to prevent or mitigate spread; a time when it is critical to implement such measures; and a period when it is time to complete mitigation steps.

The method is an elaboration of "signal-detection theory," conceived decades ago.

"Normally, when psychologists study signal detection, they are looking at very rapid changes, like whether a tone changes, whether a light changes color or turns on and off," Caldwell said.

The new approach proposes to make signal detection sensitive to more gradual events that are slower to develop.

"This is important because a pandemic is not a single point in time but a scenario that may take place in several waves over a period of months," he said. "One of the challenges is that the way influenza spreads, you don't know that someone's sick until several days later, and by then they have had the opportunity to infect other people. At that point you have to project backward to see where people have first been sick and where certain flu-related events have happened. You are reactive, rather than proactive."

The researchers envision a system that uses icons similar to those used to alert the public about an impending blizzard, hurricane or tornado. The new approach would enable public health officials to properly manage "event deadlines," or respond to a problem before it's too late.

"For example, by now we have many cases in the United States, so the event deadline for closing travel boarders with Mexico has already passed," Caldwell said.

The method also would enable officials to recognize a critical "trigger" that marks when people are prompted to act in certain ways based on a mental preview of what they think may happen in the near future.

"This trigger could be that something has already happened or you think that something is going to happen so you are doing something to prepare yourself," Caldwell said. "There are no swine flu cases yet, but you think there might be cases near where you live. You go out and buy cans of food and extra juice, and so on."

A need for such a warning system can be seen in the World Health Organization's unexpectedly rapid response to swine flu, Caldwell said.

"Health officials were very surprised that the World Health Organization went from a phase 3 pandemic alert to phase 5 in 48 hours," he said. "The pandemic preparation materials produced a few years ago stated that these sorts of decisions could be expected to evolve over several days to maybe two weeks, but not two days. So the events have unfolded much faster than people were expecting."

The research was funded by a grant from the Indiana State Department of Health through Purdue's Healthcare Technical Assistance Program, based at Purdue's Discovery Park, which strives to improve health-care performance and delivery.

In related work, the researchers have collaborated with health officials and hospitals in Indiana to determine an "alternative care system" that may need to be activated once a pandemic reaches the local area.

"A pandemic flu alternative care system is designed to respond to concerns that the existing hospital structures may not have the capacity to respond to the number of flu cases," Caldwell said. "One of the problems that we uncovered in research was that a really complex alternative care system requires even more advance planning and even more coordination of signals to know when and how to activate. Something that starts out with just a flu-information telephone number isn't bad, but we had looked at systems all the way up to temporary satellite hospitals that just handled incoming flu patients."

Previous research emphasized that counties should recognize when and what type of alternative care system would be required based on the signals officials received, determining when to activate the system based on where cases were being reported.

WHO casts wary eye on meat, blood of H1N1-infected pigs

* Flu viruses can survive freezing, be present on thawed meat

* Blood of H1N1 infected pigs may contain virus

* Meat from sick pigs or pigs found dead must not be consumed

* WHO drawing up guidelines to protect workers handling pigs

HONG KONG, 07 may 2009- Meat from pigs infected with the new H1N1 virus shouldn't be used for human consumption, the World Health Organization cautioned on Wednesday, adding it was drawing up guidelines to protect workers handling pigs.

The WHO comments appear more cautious than those from the Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE), which said import bans are not required to safeguard public health because the disease is not food-borne and has not been identified in dead animal tissue.

The WHO however said it was possible for flu viruses to survive the freezing process and be present in thawed meat, as well as in blood.

"Meat from sick pigs or pigs found dead should not be processed or used for human consumption under any circumstances," Jorgen Schlundt, director of WHO's Department of Food Safety, Zoonoses and Foodborne Diseases.

"While it is possible for influenza viruses to survive the freezing process and be present on thawed meat, there are no data available on the survival of Influenza A/H1N1 on meat nor any data on the infectious dose for people," he wrote in an email reply to questions from Reuters concerning the safety of pork, respiratory secretions and blood of H1N1-infected pigs.

Schlundt warned people to be cautious with blood and meat-juices from H1N1-infected pigs.

"The likelihood of influenza viruses to be in the blood of an infected animal depends on the specific virus. Blood (and meat-juice) from influenza H1N1-infected pigs may potentially contain virus, but at present, this has not been established," Schlundt said.

"Nonetheless, in general, we recommend that persons involved in activities where they could come in contact with large amounts of blood and secretions, such as those slaughtering/eviscerating pigs, wear appropriate protective equipment," he said.

The new H1N1 swine flu virus is being transmitted from person to person, not from pigs to people.

Its global spread has prompted many countries to limit pork imports, however. As many as 20 governments have imposed import bans on live pigs and meat from affected countries to prevent exposure to the virus. Such fears increased after Canadian authorities said on Saturday a herd of swine was infected by a farmer who had returned from Mexico.

The WHO said 22 countries have officially reported 1,534 cases of the flu virus.

While health officials say the outbreak appears to be slowing down in Mexico, authorities everywhere are asking how far the virus would spread and how serious it would be.

U.S. officials confirmed that a Texas woman with the H1N1 swine flu virus died earlier this week, the second death outside Mexico. Last week, a Mexican toddler visiting Texas died. Mexican officials have reported 29 confirmed deaths.

While the new virus is mainly spread from person to person through coughing and sneezing, experts do not know for sure how this virus came to be, which animal passed it to the first human patient and when that occurred.

But the case of the farmer infecting the pigs in Canada fueled fears of the virus yet again jumping the species barrier -- this time from pig to human -- and possibly becoming more virulent in the process.

Joseph Domenech, FAO chief veterinary officer, said on Tuesday: "This new strain of influenza virus does not contaminate humans easily and has a very low pathogenicity for both humans and pigs, unlike the avian flu which killed millions of poultry."

On Tuesday, Alex Thiermann, senior adviser to the OIE's director-general, said there was no difference between raw and cooked meat in terms of H1N1 transmission risks.

"The OIE is very concerned that differences are being made between cooked and not cooked meat. All pork products are safe for consumption," Thiermann said.

Does new swine flu virus kill by causing a 'cytokine storm'?

New Rochelle, NY, 07 may 2009—The swine flu outbreak that began in Mexico and continues to spread around the globe may be particularly dangerous for young, otherwise healthy adults because it contains genetic components of the H5N1 avian influenza virus, which can induce a "cytokine storm," in which a patient's hyper-activated immune system causes potentially fatal damage to the lungs. Research studies and review articles exploring the regulation of cytokine responses in the lung and how infection-related dysregulation can cause a cytokine storm have been published in Viral Immunology, a peer-reviewed journal published by Mary Ann Liebert, Inc. (www.liebertpub.com/vim).

A cytokine storm occurs when the body's immune system over-reacts to an intruder, such as a virus, by producing high levels of cytokines, which are signaling chemicals that help mobilize immune cells capable of removing infectious agents from the body. When too many cytokines are produced, they can stimulate an inflammatory response in which the accumulation of immune cells and fluid at the site of infection may prevent affected tissues and organs such as the lungs from functioning properly and may even cause death.

H5N1 avian influenza virus—parts of which are present in the Mexican H1N1 swine flu virus causing the current outbreak—tend to cause an unusually high proportion of deaths among healthy young adults with well-functioning immune systems who become infected, most likely due to this cytokine storm phenomenon. The Spanish influenza pandemic of 1918, for example, was particularly deadly for young healthy adults.

David L. Woodland, PhD, Editor-in Chief of Viral Immunology, and President and Director of the Trudeau Institute, Inc. (Saranac Lake, NY), emphasizes that much is still not known about the current influenza outbreak and the human/avian combination virus causing it. "We do not know how long ago this virus emerged, how deadly it is, whether it has pandemic potential, how the severity of infection relates to patient age, and why some infected patients die—whether a cytokine storm is responsible for these deaths," says Woodland.

What we do know, he adds, is that some H1N1 viruses have pandemic potential and that historical evidence supports the possibility that young healthy adults may be especially susceptible to more severe infection and poor outcomes due to the ability of a strong immune system to initiate a cytokine storm.

###

Viral Immunology is an authoritative peer-reviewed journal published bimonthly in print and online that presents the growing body of research in viral immunology. Topics cover both human and animal viral immunology, exploring viral-based immunological diseases, pathogenic mechanisms, and virus-associated tumor and cancer immunology. The Journal includes original research articles, review articles, and commentaries covering the spectrum of laboratory and clinical research and exploring developments in vaccines and diagnostics targeting viral infections. Tables of contents and a free sample issue may be viewed online at www.liebertpub.com/vim

Survey finds nearly half of Americans concerned they or their family may get sick from swine flu

Boston, MA, 01 may 2009—Following the declaration of a public health emergency due to the new H1N1 virus, also known as swine flu, the Harvard Opinion Research Program at the Harvard School of Public Health conducted a poll about how concerned Americans are about the outbreak, how they are responding and what they believe about transmission, prevention and treatment.

Concerns about the outbreak

The survey finds that nearly half of Americans are concerned (46%) that they or someone in their immediate family may get sick from swine flu during the next 12 months.

Americans' response to the outbreak

More than half of Americans are responding to the outbreak by washing their hands or using hand sanitizer more frequently (59%), and a quarter are avoiding places where many people are gathered, like sporting events, malls or public transportation (25%). Some Americans have also responded in other ways: avoiding people who they thought may have recently traveled to Mexico (20%), avoiding Mexican restaurants or stores (17%), wearing a face mask (8%), buying a face mask (5%), talking with their doctor about health issues related to swine flu (5%), or getting a prescription for antiviral medications (1%). Only a small number (4%) of parents have kept their children home from school or daycare.

"It is a good sign that most people, though not all, are taking the most important precaution recommended by the Centers for Disease Control and Prevention to prevent the spread of swine flu: washing their hands," said Robert J. Blendon, Professor of Health Policy and Political Analysis at the Harvard School of Public Health.

Beliefs about swine flu

An overwhelming majority of Americans believe that they can get the current swine flu from being in close contact with someone who has it (83%), and few believe that they can get the disease from eating pork (13%). Some Americans also believe that they can get the swine flu from being near, but not in close contact with, someone with swine flu (29%), or from being in contact with pigs (34%).

Americans are less certain about prevention and medicine for swine flu. Just over half believe that there is an effective medicine to treat the disease (54%). Most Americans (65%) don't believe that there is a vaccine to prevent the disease. About half of Americans (53%) believe that wearing a face mask could prevent them from getting sick from the swine flu, while more than three-quarters (78 percent) believe that wearing a face mask when sick would help keep them from getting others sick.

"In the days ahead it's important that public health officials explain more clearly what can be done to effectively treat those who are ill, so the public can better understand the choices that are available if they or a family member become sick," said Blendon.

Awareness of "H1N1" versus "swine flu"

The term "swine flu" has been widely used in the media to describe the current outbreak; however, recently some public health officials have used the term "H1N1 virus." The survey found that the majority of Americans (55%) have not heard of the term "H1N1" virus. Only one in five (20%) think it means the same thing as swine flu.

Methodology

This is the 29th in a series of studies on the public and biological security by the Harvard Opinion Research Program (HORP) at Harvard School of Public Health. The study was designed and analyzed by researchers at the Harvard School of Public Health (HSPH). The project director is Robert J. Blendon of the Harvard School of Public Health. The research team also includes John M. Benson, Gillian K. SteelFisher, and Kathleen J. Weldon of the Harvard School of Public Health, and Melissa J. Herrmann of SSRS/ICR. Fieldwork was conducted via telephone (including both landline and cell phone) for HORP by SSRS/ICR of Media (PA) on April 29, 2009.

The survey was conducted with a representative national sample of 1,067 adults age 18 and over, including oversamples of non-Hispanic African Americans and Hispanics. Altogether 130 non-Hispanic African Americans and 107 Hispanics were interviewed. In the overall results, these groups were weighted to their actual proportion of the total adult population.

The margin of error for the total sample is plus or minus 3.6 percentage points. Possible sources of non-sampling error include non-response bias, as well as question wording and ordering effects. Non-response in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, sample data are weighted to the most recent Census data available from the Current Population Survey for gender, age, race, education, region, and number of adults in the household. Other techniques, including random-digit dialing and systematic respondent selection within households, are used to ensure that the sample is representative.

Funding

This Harvard School of Public Health series is funded under a cooperative agreement with the Centers for Disease Control and Prevention. The award enables HORP to provide technical assistance to the Centers for Disease Control and Prevention (CDC) as well as to other national and state government health officials in order to support two critical goals: 1) to better understand the general public's response to public health emergencies, including biological threats and natural disasters; and 2) to improve related public health communications.

What you need to know about swine flu

By LAURAN NEERGAARD

WASHINGTON, 29 april 2009 – A never-before-seen strain of swine flu has turned killer in Mexico and is causing milder illness in the United States and elsewhere. While authorities say it's not time to panic, they are taking steps to stem the spread and also urging people to pay close attention to the latest health warnings and take their own precautions.

"Individuals have a key role to play," Dr. Richard Besser, acting chief of the Centers for Disease Control and Prevention, said Monday.

Here's what you need to know:

Q: How do I protect myself and my family?

A: For now, take commonsense precautions. Cover your coughs and sneezes, with a tissue that you throw away or by sneezing into your elbow rather than your hand. Wash hands frequently; if soap and water aren't available, hand gels can substitute. Stay home if you're sick and keep children home from school if they are.

Q: How easy is it to catch this virus?

A: Scientists don't yet know if it takes fairly close or prolonged contact with someone who's sick, or if it's more easily spread. But in general, flu viruses spread through uncovered coughs and sneezes or — and this is important — by touching your mouth or nose with unwashed hands. Flu viruses can live on surfaces for several hours, like a doorknob just touched by someone who sneezed into his hand.

Q: In Mexico, officials are handing out face masks. Do I need one?

A: The CDC says there's not good evidence that masks really help outside of health care settings. It's safer just to avoid close contact with someone who's sick and avoid crowded gatherings in places where swine flu is known to be spreading. But if you can't do that, CDC guidelines say it's OK to consider a mask — just don't let it substitute for good precautions.

Q: Is swine flu treatable?

A: Yes, with the flu drugs Tamiflu or Relenza, but not with two older flu medications.

Q: Is there enough?

A: Yes. The federal government has stockpiled enough of the drugs to treat 50 million people, and many states have additional stocks. As a precaution, the CDC has shipped a quarter of that supply to the states to keep on hand just in case the virus starts spreading more than it has so far.

Q: Should I take Tamiflu as a precaution if I'm not sick yet?

A: No. "What are you going to do with it, use it when you get a sniffle?" asks Dr. Marc Siegel of New York University Langone Medical Center and author of "Bird Flu: Everything you Need To Know About The Next Pandemic." Overusing antiviral drugs can help germs become resistant to them.

Q: How big is my risk?

A: For most people, very low. Outside of Mexico, so far clusters of illnesses seem related to Mexican travel. New York City's cluster, for instance, consists of students and family members at one school where some students came back ill from spring break in Mexico.

Q: Why are people dying in Mexico and not here?

A: That's a mystery. First, understand that no one really knows just how many people in Mexico are dying of this flu strain, or how many have it. Only a fraction of the suspected deaths have been tested and confirmed as swine flu, and some initially suspected cases were caused by something else.

Q: Should I cancel my planned trip to Mexico?

A: The U.S. did issue a travel advisory Monday discouraging nonessential travel there.

Q: What else is the U.S., or anyone else, doing to try to stop this virus?

A: The U.S. is beginning limited screening of travelers from Mexico, so that the obviously sick can be sent for treatment. Other governments have issued their own travel warnings and restrictions. Mexico is taking the biggest steps, closings that limit most crowded gatherings. In the U.S., communities with clusters of illness also may limit contact — New York closed the affected school for a few days, for example — so stay tuned to hear if your area eventually is affected.

Q: What are the symptoms?

A: They're similar to regular human flu — a fever, cough, sore throat, body aches, headache, chills and fatigue. Some people also have diarrhea and vomiting.

Q: How do I know if I should see a doctor? Maybe my symptoms are from something else — like pollen?

A: Health authorities say if you live in places where swine flu cases have been confirmed, or you recently traveled to Mexico, and you have flulike symptoms, ask your doctor if you need treatment or to be tested. Allergies won't cause a fever. And run-of-the-mill stomach bugs won't be accompanied by respiratory symptoms, notes Dr. Wayne Reynolds of Newport News, Va., spokesman for the American Academy of Family Physicians.

Q: Is there a vaccine to prevent this new infection?

A: No. And CDC's initial testing suggests that last winter's flu shot didn't offer any cross-protection.

Q: How long would it take to produce a vaccine?

A: A few months. The CDC has created what's called "seed stock" of the new virus that manufacturers would need to start production. But the government hasn't yet decided if the outbreak is bad enough to order that.

Q: What is swine flu?

A: Pigs spread their own strains of influenza and every so often people catch one, usually after contact with the animals. This new strain is a mix of pig viruses with some human and bird viruses. Unlike more typical swine flu, it is spreading person-to-person. A 1976 outbreak of another unusual swine flu at Fort Dix, N.J., prompted a problematic mass vaccination campaign, but that time the flu fizzled out.

Q: So is it safe to eat pork?

A: Yes. Swine influenza viruses don't spread through food.

Q: And whatever happened to bird flu? Wasn't that supposed to be the next pandemic?

A: Specialists have long warned that the issue is a never-before-seen strain that people have little if any natural immunity to, regardless of whether it seems to originate from a bird or a pig. Bird flu hasn't gone away; scientists are tracking it, too.

WHO says possible swine flu pandemic may be mild

GENEVA, 29 april 2009- The World Health Organization said on Tuesday the current outbreak of swine flu could lead to only a mild pandemic but warned the 1918 flu pandemic, which killed tens of millions, started that way.

"It is entirely possible...that we may see a very mild pandemic. That would be the best of all situations short of this current situation simply stopping and disappearing," Keiji Fukuda, WHO acting assistant director-general, told reporters.

"I think we have to be mindful and respectful of the fact that influenza moves in ways we cannot predict.

"The worst pandemic of the 20th century occurred ... in 1918 and it also started out as a relatively mild pandemic that wasn't very much noticed in most places. Then in the fall time (it) became a very severe pandemic, one of the most severe infectious disease episodes ever recorded."

The new strain of swine flu virus that has killed up to 149 people in Mexico spread to more countries on Tuesday, raising the specter of a pandemic and hurting financial markets.

Fukuda, an American specialist in influenza, said that there was no good explanation for why the cases in Mexico appeared to be more severe than in other countries. Seven of the 26 laboratory-confirmed cases in Mexico had died, he said.

Worldwide, a total of 79 cases have now been confirmed in laboratories recognized by the WHO and officially notified to the United Nations agency. The latest are three cases in New Zealand, two cases in Britain and a second case in Spain.

Fukuda said there was a definite possibility that the new virus could establish community-wide infections in multiple countries, but it was too early to say that this was inevitable.

The WHO was turning its focus more toward the needs of developing countries, which history shows usually lack resources and infrastructure to combat emerging infectious diseases.

"They really get hit disproportionately hard," he said.

Officials say US deaths expected from swine flu

By SARA KUGLER

NEW YORK, 29 april 2009 – The global swine flu outbreak worsened Tuesday as authorities said hundreds of students at a New York school have fallen ill and federal officials said they expected to see U.S. deaths from the virus. Cuba suspended flights to and from Mexico, becoming the first country to impose a travel ban to the epicenter of the epidemic.

The mayor of the capital cracked down further on public life, closing gyms and swimming pools and ordering restaurants to limit service to takeout.

Confirmed cases were reported for the first time as far away as New Zealand and Israel, joining the United States, Canada, Britain and Spain.

Swine flu is believed to have killed more than 150 people in Mexico, and the Centers for Disease Control and Prevention said the U.S. has 68 confirmed cases in five states, with 45 in New York, one in Ohio, one in Indiana, two in Kansas, six in Texas and 13 in California.

"I fully expect we will see deaths from this infection," said Richard Besser, acting director of the CDC.

That was echoed by Homeland Security Secretary Janet Napolitano.

"It is very likely that we will see more serious presentations of illness and some deaths as we go through this flu cycle," she said.

President Barack Obama asked Congress for $1.5 billion in emergency funds to fight the illness.

In New York, there were growing signs that the virus was moving beyond St. Francis Preparatory school, where sick students started lining up last week at the nurse's office. The outbreak came just days after a group of students returned from spring break in Cancun.

At the 2,700-student school, the largest Roman Catholic high school in the nation, "many hundreds of students were ill with symptoms that are most likely swine flu," said Health Commissioner Thomas Frieden. The cases haven't been confirmed.

Twelve teachers reported flu-like symptoms as well, said the principal, Brother Leonard Conway.

A nearby public school for special education students was shut down after more than 80 students called in sick. Frieden said that some of the students have siblings at St. Francis.

"It is here and it is spreading," Frieden said.

Some of the New York students who tested positive for swine flu after a trip to Mexico passed it on to others who had not traveled — a significant fact because it suggests the strain suspected in dozens of deaths in Mexico can also spread through communities in other countries, said Keiji Fukuda, assistant director-general of the World Health Organization.

"There is definitely the possibility that this virus can establish that kind of community wide outbreak capacity in multiple countries, and it's something we're looking for very closely," Fukuda said. So-called "community" transmissions are a key test for gauging whether the spread of the virus has reached pandemic proportions.

Fukuda warned, however, against jumping to the conclusion that the virus has become firmly established in the United States.

Still, U.S. officials stressed there was no need for panic and noted that flu outbreaks are quite common every year. The CDC estimates about 36,000 people in the U.S. died of flu-related causes each year, on average, in the 1990s.

The increase in cases was not surprising. For days, CDC officials said they expected to see more confirmed cases — and more severe illnesses. Health officials nationwide stepped up efforts to look for symptoms, especially among people who had traveled to Mexico.

Scientists hope to have a key ingredient for a vaccine ready in early May, but it still will take a few months before any shots are available for the first required safety testing. Using samples of the flu taken from people who fell ill in Mexico and the U.S., scientists are engineering a strain that could trigger the immune system without causing illness.

"We're about a third of the way" to that goal, said Dr. Ruben Donis of the CDC.

The economic toll also spread. Officials said Mexico City is losing $57 million a day amid a shutdown that includes schools, state-run theaters and other public places.

Cuba announced a 48-hour ban on flights to and from Mexico, except in "exceptional cases." The last flight from Mexico touched down in Havana around 4 p.m., then returned to Mexico City with passengers before the two-day suspension officially began.

The U.S. stepped up checks of people entering the country and warned Americans to avoid nonessential travel to Mexico. Canada, Israel and France issued similar travel advisories.

For all the government intervention, health officials suggested that efforts to contain the flu strain might prove ineffective. Around the world, officials hoped the outbreak would not turn into a full-fledged pandemic, an epidemic that spreads across a wide geographical area.

"Border controls do not work. Travel restrictions do not work," said WHO spokesman Gregory Hartl, recalling the SARS epidemic earlier in the decade that killed 774 people, mostly in Asia, and slowed the global economy.

The pork industry was dealing with a public relations nightmare over the virus, which is a never-before-seen hybrid of human, swine and bird influenza that is widely called swine flu.

Public health officials have said people cannot get sick from eating pork, but some countries, such as China, Russia and Ukraine, have banned imports from Mexico and parts of the U.S.

U.S. officials said they may abandon the term "swine flu" for fear of confusing people into thinking they could catch it from eating pork.

"It's killing our markets," said Francis Gilmore, 72, who runs a 600-hog operation in Perry, Iowa, outside Des Moines, and worries his small business could be ruined by the crisis. "Where they got the name, I just don't know."

Gov. Arnold Schwarzenegger declared a state of emergency to help California agencies coordinate efforts in response to the outbreak. He cautioned, however, that "there is no need for alarm."

In New York, the city called on the CDC for additional resources to investigate the outbreak at St. Francis Prep.

About 1,500 students replied to surveys sent out by the health department about the outbreak, helping the city get a better sense of how the virus is spreading. Some students have complained of sudden nausea; others dealt with high fever, sore throats, coughs and aches.

Rachel Mele and her mother, Linda, were relieved when the 16-year-old's fever broke Tuesday for the first time in five days. It had been hovering around 101.

The family could finally breathe easy — a relief after a terrifying night Thursday in which Mele's parents bundled her into the car and rushed her to the hospital when they realized she was having trouble breathing.

"I could barely even catch my breath. I've never felt a pain like that before," Mele said. "My throat, it was burning, like, it was the worst burning sensation I ever got before. I couldn't even swallow. I couldn't even let up air. I could barely breathe through my mouth."

FDA allows uncleared uses of flu drugs, tests

WASHINGTON, 29 april 2009 - The U.S. Food and Drug Administration authorized emergency uses of the flu drugs Tamiflu and Relenza on Monday and a diagnostic test to help get a grip on a new strain of swine flu, the agency said on Monday.

The U.S. government's declaration on Sunday that the swine flu is a public health emergency freed the FDA to take such action, the agency said in a statement.

The FDA will now have the authority to allow public health and medical personnel to prescribe Relenza, GlaxoSmithKline's inhaled flu drug also known as zanamivir, and Roche AG's Tamiflu, a pill also known as oseltamivir, for unapproved uses.

Tamiflu, approved for treating and preventing the flu in people over a year old, can now be used in children under 1 year. Doctors can also change the recommended dosage for children older than 1 year under the emergency use authorization.

The FDA also gave more healthcare workers authority to distribute Tamiflu and Relenza, including some public health officials and volunteers.

More than 40 people have been sickened by the new flu strain in the United States.

The rRT-PCR Swine Flu Panel diagnostic test was authorized for testing samples from flu patients to determine if they have the new strain.

A positive finding will presumptively conclude that the patient has the new, previously unseen strain of H1N1 swine flu. But a negative result will not be considered conclusive that a patient does not have the virus, the agency said.

New swine flu infections intensify travel fears

By Catherine Bremer

MEXICO CITY , 29 april 2009- New swine flu infections were found around the world on Tuesday and the specter of a pandemic hit the travel industry as governments warned people to stay away from Mexico where 149 people have died.

The number of infections in the United States rose to 65, Canada has 13, and new cases were also confirmed in Israel and New Zealand.

The United States, Canada and the European Union are telling people to avoid non-essential travel to Mexico, and Cuba suspended all flights to and from Mexico for 48 hours.

Travel companies were also staying away. Carnival Cruises canceled stops at Mexican ports for three of its ships on Tuesday and Canadian tour operator Transat AT postponed flights to Mexico until June 1.

President Barack Obama asked the U.S. Congress for $1.5 billion to finance its response to the flu threat, and California declared a state of emergency, allowing it to deploy more resources to prevent new infections.

The World Health Organization said a pandemic -- a global outbreak of a serious new illness -- is not yet inevitable but that all countries should prepare for the worst, especially poorer developing nations.

"They really get hit disproportionately hard," said the WHO's acting assistant director-general Dr. Keiji Fukuda.

One of the mysteries of the outbreak is why the virus has killed scores of people in Mexico while the cases outside the country have been relatively mild and no one has died.

Experts say this may be simply a matter of where they have been looking to find it and officials say they expect to find deaths as the disease spreads.

A pandemic could snuff out fragile signs of economic recovery around the world as travel, trade and manufacturing output would all be hit.

The last flu pandemic was in 1968, when "Hong Kong" flu killed about 1 million people around the world.

Seven countries have confirmed cases of the swine flu and a dozen others have suspected infections.

Mexico City is at the center of the outbreak and many residents are staying in their homes while schools, churches, cinemas and restaurants have all been shut down.

Airline share prices declined again on Tuesday on fears that they could experience a sharp drop in traffic.

U.S., European and Asian stock markets all retreated despite positive U.S. consumer confidence data as flu fears and worries about American banks weighed on sentiment.

"Prices remain in a bit of a swoon as market participants fret that a potential influenza pandemic might prove fatal to the frail signs of recovery just beginning to show," said Mike Fitzpatrick, vice president at MF Global in New York.

Oil dropped almost 2 percent to below $50 a barrel and investors cut their exposure to riskier currencies.

The swine flu virus is not caught from eating pig meat products but several countries, led by Russia and China, banned U.S. pork imports. The EU said it has no plans to restrict pig meat products from the United States.

TRAVEL ALERTS

A barrage of travel warnings by foreign governments and travel firms threatened to batter Mexico's tourism industry, a main source of foreign currency for the country.

UK travel firms Thomson Holidays and First Choice decided to repatriate their customers from Mexico and cancel flights bound for Cancun, although most airlines continued to operate their services.

Many private companies took their own precautions, restricting travel to Mexico and other countries with confirmed cases. Honda Motor Co, which like most major auto makers has production facilities in Mexico, has suspended all global business travel until at least May 6.

Experts say that while it is impossible to stop the spread of the disease, efforts to slow its progress could buy crucial time for countries to procure essential drugs.

The WHO's Fukuda said a mild pandemic is possible but he also cautioned that the 1918 "Spanish" flu that killed tens of millions of people emerged from mild beginnings.

Worldwide, seasonal flu kills between 250,000 and 500,000 people in an average year.

In Mexico, people from company directors to couriers wore face masks while airlines checked passengers for flu symptoms.

The government has shut all schools across Mexico until at least May 6. Restaurants, bars, cinemas and even churches in the capital have been closed to limit new infections.

Residents rushed to stock up on food, water and surgical masks but the usually hectic city is otherwise very quiet.

Mexico says the first fatal case that alerted authorities to the strange new virus was in the southern state of Oaxaca but they have not yet found the origin of the outbreak.

Mexico fights swine flu with 'pandemic potential'

MEXICO CITY, 26 april 2009 – Mexico's president assumed new powers Saturday to isolate people infected with a deadly swine flu strain as authorities struggled to contain an outbreak that world health officials warned could become a global epidemic.

New cases of swine flu were confirmed in Kansas and California and suspected in New York City, but health officials said they didn't know whether it was the strain that has killed up to 68 people in Mexico and likely sickened more than 1,000.

Mexican soldiers and health workers patrolled airports and bus stations as they tried to corral people who may be infected with the swine flu, as it became clearer that the government may have been slow to respond to the outbreak in March and early April.

Now, even detaining the ill may not keep the strain — a combination of swine, bird and human influenza that people may have no natural immunity to — from spreading, epidemiologists say.

The World Health Organization on Saturday asked countries around the world to step up reporting and surveillance of the disease and implement a coordinated response to contain it.

Two dozen new suspected cases were reported in Mexico City alone, where authorities suspended schools and all public events until further notice. More than 500 concerts, sporting events and other gatherings were canceled in the metropolis of 20 million.

The Mexican government issued a decree authorizing President Felipe Calderon to invoke special powers letting the Health Department isolate patients and inspect homes, incoming travelers and baggage.

Officials said the decree gives clear legal authority to Health Department workers who might otherwise face reprisals.

At Mexico City's international airport, health workers passed out written questionnaires seeking to identify passengers with flu symptoms. Surgical masks and brochures were handed out at bus and subway stations. The U.S. embassy in Mexico posted a message advising U.S. citizens to avoid large crowds, shaking hands, greeting people with a kiss or using the subway.

But with confirmed swine flu cases in at least six states — and possibly as many as 14 — the efforts seemed unlikely to stop the spread of the disease.

Particularly difficult in a metropolis as crowded as Mexico City was the embassy's advice to maintain "a distance of at least 6 feet from other persons may decrease the risk of exposure."

WHO Director-General Margaret Chan said the outbreak of the never-before-seen virus has "pandemic potential." But she said it is still too early to tell if it would become a pandemic.

"The situation is evolving quickly," Chan said in Geneva. "A new disease is by definition poorly understood."

WHO lays out three criteria necessary for a global epidemic to occur: The virus is able to infect people, can readily spread person-to-person and the global population has no immunity to it. The agency held off raising its pandemic alert level, citing the need for more information. Out of the many cases in Mexico reported, relatively few samples have been tested.

Early detection and treatment are key to stopping any outbreak. WHO guidance calls for isolating the sick and blanketing everyone around them with antiviral drugs such as Tamiflu.

Now, with patients showing up all across Mexico and its teeming capital, simple math suggests that kind of response is impossible.

Mexico appears to have lost valuable days or weeks in detecting the new virus.

Health authorities started noticing a threefold spike in flu cases in late March and early April, but they thought it was a late rebound in the December-February flu season.

Testing at domestic labs did not alert doctors here to the new strain, although U.S. authorities detected an outbreak in California and Texas last week.

Perhaps spurred by the U.S. discoveries, Mexico sent 14 mucous samples to the CDC April 18 and dispatched health teams to hospitals looking for patients with severe flu or pnuemonia-like symptoms.

Those teams noticed something strange: The flu was killing people aged 20 to 40. Flu victims are usually either infants or the elderly. The Spanish flu pandemic, which killed at least 40 million people worldwide in 1918-19, also first struck otherwise healthy young adults.

As recently as Wednesday, authorities were referring to it as a late-season flu.

But mid-afternoon Thursday, Mexico City Health Secretary Dr. Armando Ahued said, officials got a call "from the United States and Canada, the most important laboratories in the field, telling us this was a new virus."

"That was what led us to realize it wasn't a seasonal virus ... and take more serious preventative measures," Health Secretary Jose Cordova said.

Some Mexicans suspected the government had been less than forthcoming. "They always make a big deal about good things that happen, but they really try to hide anything bad," Mexico City paralegal Gilberto Martinez said.

Hospitals dealt with crowds of people seeking help. A hot line fielded 2,366 calls in its first hours from frightened city residents who suspected they might have the disease.

Doctors reported that anti-viral medications and even steroids were working well against the disease, noting no new deaths had been reported in the capital in the last day.

Airports around the world were screening travelers from Mexico for flu symptoms. But containing the disease may not be an option.

"Anything that would be about containing it right now would purely be a political move," said Michael Osterholm, a University of Minnesota pandemic expert.

Ahued, the capital's health secretary, said Mexico City may not even be the epicenter of the outbreak.

"The country's best health care facilities are concentrated in the city," he said. "All the cases here get reported, that's why the number is so high."

Scientists have warned for years about the potential for a pandemic from viruses that mix genetic material from humans and animals.

This swine flu and regular flu can have similar symptoms — mostly fever, cough and sore throat, though some of the U.S. victims who recovered also experienced vomiting and diarrhea. But unlike with regular flu, humans don't have natural immunity to a virus that includes animal genes — and new vaccines can take months to bring into use.

The same virus also sickened at least 11 people in the United States, though there have been no deaths north of the border.

The Kansas Department of Health and Environment on Saturday confirmed two cases of swine flu in two adults in the same household. One of the patients had recently traveled to Mexico. Another eight students at a New York City high school probably have human swine influenza, but health officials said they don't know for sure whether it is the same strain.

A "seed stock" genetically matched to the new swine flu virus has been created by the CDC, said Dr. Richard Besser, the agency's acting director. If the government decides vaccine production is necessary, manufacturers would need that stock to get started.

None of that provided any easy answers to Mexico City residents, who reacted with fatalism and confusion, anger and mounting fear at the idea that their city may be ground zero for a global epidemic.

Outside Hospital Obregon in the capital's middle-class Roma district, a tired Dr. Roberto Ortiz, 59, leaned against an ambulance and sipped coffee Saturday on a break from an unusually busy shift.

"The people are scared," Ortiz said. "A person gets some flu symptoms or a child gets a fever and they think it is this swine flu and rush to the hospital."

He said none of the cases so far at the hospital had turned out to be swine flu.

Questions and answers about swine flu

26 april 2009--Mexico is contending with an outbreak of swine flu, suspected in the deaths of dozens of people and sickening perhaps 1,000. In the United States, at least eight cases have been confirmed with the infection, all of them in California and Texas; only one person was hospitalized. Here are some questions and answers about the illness:

Q. What is swine flu?

A. Swine flu is a respiratory illness in pigs caused by a virus. The swine flu virus routinely causes outbreaks in pigs but doesn't usually kill many of them.

Q. Can people get swine flu?

A. Swine flu viruses don't usually infect humans. There have been occasional cases, usually among people who've had direct contact with infected pigs, such as farm workers. "We've seen swine influenza in humans over the past several years, and in most cases, it's come from direct pig contact. This seems to be different," said Dr. Arnold Monto, a flu expert with the University of Michigan.

Q. Can it spread among humans?

A. There have been cases of the virus spreading from human to human, probably in the same way as seasonal flu, through coughing and sneezing by infected people.

Q. What are the symptoms of swine flu?

A. The symptoms are similar to those of regular flu — fever, cough, fatigue, lack of appetite.

Q. Is the same swine flu virus making people sick in Mexico and the U.S.?

A. The Centers for Disease Control and Prevention said the Mexican virus samples match the U.S. virus. The virus is a mix of human virus, bird virus from North America and pig viruses from North America, Europe and Asia.

Q. Are there drugs to treat swine flu in humans?

A. There are four different drugs approved in the U.S. to treat the flu, but the new virus has shown resistance to the two oldest. The CDC recommends the use of the flu drugs Tamiflu and Relenza.

Q. Does a regular flu shot protect against swine flu?

A. The seasonal flu vaccine used in the U.S. this year won't likely provide protection against the latest swine flu virus. There is a swine flu vaccine for pigs but not for humans.

Q. Should residents of California or Texas do anything special?

A. The CDC recommends routine precautions to prevent the spread of infectious diseases: wash your hands often, cover your nose and mouth when you cough or sneeze, avoid close contact with sick people. If you are sick, stay at home and limit contact with others.

Q. What about traveling to Mexico?

A. The CDC has not warned Americans against traveling to Mexico but advises that they be aware of the illnesses there and take precautions to protect against infections, like washing their hands.

___

Source: Centers for Disease Control and Prevention

Swine Flu is Public Health Emergency, With New U.S. Cases

26 april 2009--The World Health Organization declared a deadly new strain of swine flu to be a "public health emergency of international concern," as health officials identified possible new cases in two additional U.S. states and called the disease widespread.

Several children at a school in the New York City borough of Queens may have been infected, and two people were confirmed with the disease in Kansas, according to reports from local health departments. The U.S. Centers for Disease Control and Prevention said it expects to find more cases soon throughout the country.

Swine Flu Strain Hits U.S. Cities

1:57

The World Health Organization has stepped up operations after eight school kids in New York and two other people in Kansas tested positive for a strain of the swine flu.

In Geneva, WHO Director-General Margaret Chan warned Saturday that the virus had the potential to cause a pandemic, but cautioned that it was too early to tell whether it would erupt into a global outbreak. Following an emergency meeting Saturday, a WHO panel declared the developments thus far a public health emergency and urged governments around the world to intensify surveillance for unusual outbreaks of flu-like illness and severe pneumonia. But the panel held off on raising a global pandemic alert, saying it needed more information before making a decision.

Mexican health authorities said the death toll from the new strain of A/H1N1 swine flu remains at 20, and they are continuing to investigate whether more than 1,000 others were infected with the mysterious bug, which attacked in three geographically diverse areas of the country and is taking its heaviest toll in young adults.

The CDC said early Saturday afternoon the number of confirmed cases of the new flu in the U.S. remained at eight, but it expects to identify more soon. A statement from the Kansas Department of Health and Environment Saturday afternoon said the CDC had additionally confirmed swine flu infection in two people, bringing the U.S. total to 10.

In New York City, further testing will be required to know whether more than 100 of roughly 2,700 students at St. Francis Preparatory School in Queens were ill with swine flu when they missed school last week, said Thomas Frieden, the city's health commissioner. Health officials have interviewed most of the ill students or their families; all reported mild symptoms, and none required hospitalization.

The health department has tested nine samples taken from ill students, eight of which have been classified "probable human swine influenza," Dr. Frieden said. Local testing confirmed that the samples were influenza type A, which occurs in both humans and swine, and the samples did not match common subtypes of human influenza. Under current CDC definitions, cases of influenza type A that do not match subtypes of human influenza are considered probable swine flu, pending confirmation by the CDC.

More

• Scientists Fear People Spread New Swine Flu
• Health Blog Q&A: The Swine Flu Outbreak

The samples have been sent to the CDC for additional testing, Dr. Frieden said. Results could be available as soon as tomorrow. If swine flu is confirmed, the health department will recommend that the school cancel classes on Monday to reduce the risk of further spread.

The city health department is also investigating a report of about 30 children who became ill at a day-care center in the Bronx. But Dr. Frieden emphasized that the status in that case remains unclear and may turn out to be unrelated to swine flu.

The CDC has sent teams to California, Texas, and Mexico to assist with investigations. Confirmed cases include six children and adults in San Diego and Imperial Counties in Southern California. Two 16 year-old boys in Guadalupe County near San Antonio, Tex., were also found to have had the disease. Only one of the cases, a 41 year-old woman, was hospitalized, and the others had only mild disease, the CDC said.

It's unclear so far why U.S. cases identified so far are mostly mild, while Mexico has experienced severe disease, Dr. Schuchat said, though expanded surveillance is likely to yield more clues.

The CDC is also taking initial steps toward preparing a vaccine should that become necessary, but producing enough for a mass vaccination program could take months, Dr. Schuchat cautioned.

President Felipe Calderon urged Mexicans to remain calm and reassured them that government has plenty of antiviral medicines to treat the outbreaks. Two antiviral medications, marketed as tamiflu and relenza, both work against the bug, according to the CDC.

In Mexico City, blue surgical masks proliferated and entrepreneurs were selling them on the streets. Two soccer games scheduled for Sunday are expected to be played in front of empty stadiums but broadcast on TV.