U.S. - First Tamiflu-resistant swine flu (Singapore ex-Hawaii)

[HenryN]

A 28-year-old American woman who is working here. She returned to Singapore from Honolulu via Tokyo on Tuesday 11.53pm on United Airlines, UA803. She was seated at 33C.

It is likely that the above description is of the first Tamiflu resistance case, represented by isolate A/Singapore/57/2009 which was from a 28F isolated on May 30, 2009.

It is unlikely that this patient was treated with Tamiflu prior to sample collection.

[Rwilmer]

HHMM, Tamiflu resistance has been around for a while I guess.

[HenryN]

One May 30, the number of confirmed cases in Singapore was limited. The above patient is the only 28F among the first cases.

Reported Location: Singapore
Confirmed Cases: 1104
Fatal Cases: 5

This is an aggregated report based on 31 reports near the same location.

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Report Date: 7/27/2009
Reported Location: Singapore
Confirmed Cases: 1
Fatal Cases: 1
Influenza A(H1N1)-related fatalities in Singapore rose to five when a woman, who also had acute myeloid leukaemia, died on Monday. The 34-year-old Chinese woman was admitted to the Singapore General Hospital on 17 July after two days of cough. She was transferred to the Intensive Care Unit (ICU) on 19 July because of low oxygen saturation. She passed away on Monday morning and the cause of death is pneumonia, with Influenza A (H1N1) infection as a contributing factor, said a Ministry of Health statement. Meanwhile, four more H1N1 patients were admitted into ICU. One of them was a 9-year-old Chinese girl who had been warded in the National University Hospital (NUH) since June for treatment of encephalitis. She has a history of cerebral palsy, quadriplegia and hypothyroidism. She was transferred to the Pediatric ICU on 25 July for respiratory distress. Laboratory tests confirmed she has Influenza A (H1N1). She is on ventilator support and her condition is stable. The second case was a 23-year-old Malay man who had a history of epileptic fits. He developed high fever, drowsiness and seizures on 25 July, and was admitted directly from the Emergency Department to the ICU on 26 July. Laboratory tests confirmed he has Influenza A (H1N1). His condition is stable. The third patient was a 29-year-old Indian woman with no previous medical history. She sought treatment at Changi General Hospital (CGH) Emergency Department on 25 July after two days of fever, cough and chest discomfort. She was admitted to ICU on 26 July. Laboratory tests confirmed she has Influenza A(H1N1). She is on ventilator support and her condition is stable. The fourth patient admitted into ICU was a 34-year-old Chinese man with a history of Down\'s syndrome. He sought treatment at CGH\'s Emergency Department on 23 July after two weeks of cough, sore throat and fever. He developed bilateral pneumonia and acute respiratory distress syndrome, and was transferred to the ICU on 26 July. Laboratory tests confirmed he has Influenza A(H1N1). He is on ventilator support and is on the dangerously ill list. The executive director of the Genome Institute of Singapore, Professor Edison Liu, said fatalities are likely to increase as the flu cycle continues. But it would make no sense to invest in H1N1 vaccine research in Singapore because pharmaceutical companies have almost developed one.
Source: http://www.channelnewsasia.com/stories/singaporelocalnews/view/445029/1/.html

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Report Date: 5/27/2009
Reported Location: Singapore
Confirmed Cases: 1
A 22-year-old Singaporean woman was confirmed to be Singapore\'s first case of Influenza A/H1N1 on Wednesday. According to TV broadcaster Channel NewsAsia, the patient was in New York from May 14 to 24, and returned to Singapore from New York on SQ25 on May 26 at 6:30 a.m. local time. Singapore\'s Health Ministry (MOH) said it has initiated contact tracing of her close contacts. Passengers who had traveled in the same flight and were seated in rows 52 to 58 are urged to call the local hotline to check on their health condition. They will be quarantined and provided with antiviral prophylaxis. The report said the patient began to develop cough symptom while onboard, but she passed the thermal scanner at the airport as she did not have fever then. She later consulted a local clinic doctor who decided to send her for testing, given her travel history. Laboratory confirmation of her infection was made by midnight of May 26, the report said.
Source: http://news.xinhuanet.com/english/2009-05/27/content_11442563.htm

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Report Date: 5/28/2009
Reported Location: Singapore
Confirmed Cases: 2
SINGAPORE on Thursday confirmed three more cases of Influenza A (H1N1). The patients are being treated at the Communicable Disease Centre at Tan Tock Seng Hospital (TTSH). Their symptoms are relatively mild and all of them are in stable condition, said a statement from Ministry of Health on Thursday night. The latest patients, bringing the total cases so far to four, are: A 43-year-old woman Permanent Resident who returned to Singapore from San Francisco via Manila on Tuesday at 5.50pm. She was on Singapore Airlines flight SQ917 and was seated at 33H. She became unwell while on board. A 28-year-old American woman who is working here. She returned to Singapore from Honolulu via Tokyo on Tuesday 11.53pm on United Airlines, UA803. She was seated at 33C. A 28-year-old Singaporean man who returned to Singapore from Chicago via Hong Kong just past midnight on Monday. He was on United Airlines, UA895 and was seated at 55H.
Source: http://www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_382905.html?vgnmr=1

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Report Date: 5/31/2009
Reported Location: Singapore
Confirmed Cases: 1
A 22-YEAR-OLD Singaporean female has been confirmed as the fifth case of the H1N1 flu in Singapore, the Ministry of Health said in a statement on Sunday. The patient was in the United States from 13 to 28 May and returned to Singapore from New York via Tokyo on an All Nippon Airways flight. She passed the thermal scanners at Changi Airport as she did not have a fever then. However, the patient developed a fever the next morning and her mother drove her to Tan Tock Seng hospital. She was admitted to the Communicable Disease Centre (CDC) and laboratory tests confirmed her infection the same day. According the MOH, the patient is in stable condition and her symptoms are mild.
Source: http://www.straitstimes.com/Breaking+News/Singapore/Singapore.html

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Report Date: 6/4/2009
Reported Location: Singapore
Confirmed Cases: 1
SINGAPORE confirmed its 12th case of Influenza A (H1N1-2009) on Thursday. The patient is an 18-year-old Singaporean male. He went to Melbourne on May 16 and returned to Singapore on Emirates EK405 on Monday at 11.50 pm, said a Ministry of Health statement on Thursday night. He was seated at row 18. He was sent to Tan Tock Seng Hospital emergency department on Thursday noon by ambulance via 993. Laboratory results copnfirmed his infection at 7.25 pm on Thursday and he was admitted to the Communicable Disease Centre. Contact tracing is ongoing for the latest case, said MOH.
Source: http://www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_386009.html

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Report Date: 6/5/2009
Reported Location: Singapore
Confirmed Cases: 2
Singapore confirmed two more cases of Influenza A/H1N1 on Friday, bringing the number of total cases here to 14. According to Singapore\'s Health Ministry, the 13th confirmed case is a 23-year-old Singaporean male who went to Melbourne on May 27 and returned to Singapore on Singapore Airlines SQ238 on Thursday. He was detected having a fever by the thermal scanner at Changi Airport and was sent to local hospitals on the same day. The 14th confirmed case is a 22-year-old Singaporean female who is a cabin crew with Singapore Airlines and went to New York on May 24. She was on the same flight (SQ25) from New York to Frankfurt as three of Singapore\'s earlier confirmed cases. While these three earlier confirmed cases arrived in Singapore on Monday, she had stopped over at Frankfurt and returned to Singapore one day later on Tuesday. She developed symptoms on Wednesday and was sent to hospital on Thursday. The Health Ministry said that laboratory results confirmed the two cases on Friday, adding that both patients have relatively mild symptoms and are in stable condition. The ministry said that contact tracing has been initiated for the two newly confirmed cases.
Source: http://news.xinhuanet.com/english/2009-06/05/content_11495976.htm

[HenryN]

The posts below are from a message board in Singapore, listing initial cases (from media reports, but no links). None are a 28F:

http://www.funkygrad.com/forum/read_...shout&tid=1815

Author	Topic: We got it: Singapore's 1st H1N1 flu case
pinebabe Very Senior Member Total Posts: 902	posted Wed 27 May 2009 11:41 AM We finally got it. SINGAPORE, May 27 (Reuters) - The Singapore government on Wednesday confirmed the city-state's first H1N1 flu case, a 22-year-old Singaporean woman who is being quarantined in hospital and is the latest of nearly 13,000 cases worldwide. The government has been warning Singaporeans for weeks to prepare for an inevitable H1N1 outbreak in the city-state, a regional financial and trading centre and the world's busiest port. The woman arrived from New York early on Tuesday on a Singapore Airlines flight, and was not picked up by thermal scanners at the airport as she did not have a fever then, the government said in a statement. She is in a stable condition. The government said it was tracing the flu patient's close contacts and said they would be quarantined and treated with anti-viral medication. It urged those travelling on the same flight to contact the authorities. The government is continuing with screening at border checkpoints and asked people to stay at home if suffering flu symptoms. It also advised caution over travel to affected areas.
pinebabe Very Senior Member Total Posts: 902	posted Wed 27 May 2009 12:13 PM The patient is currently being treated at the Communicable Disease Centre at Tan Tock Seng Hospital and is in stable condition. The patient is a 22-year-old Singaporean woman who was in New York from May 14-24. She arrived back in Singapore from New York on SQ25 on 26 May at 6.30am. She began to develop a cough while onboard. She passed the thermal scanner uneventfully as she did not have fever then. Later in the morning, she consulted a GP who decided to send her to TTSH via a 993 ambulance, given her travel history. She was immediately admitted for testing. Laboratory confirmation of her infection was made by midnight of 26 May. The patient has been vigilant in monitoring her own condition and had sought immediate medical attention once she realized that she was unwell. Her attending GP, through his quick response in activating the 993 ambulance for the patient, had also helped to minimize the spread of infection from this case. The Health Ministry says it has initiated contact tracing of her close contacts. They will be quarantined and provided with antiviral prophylaxis. Passengers who had travelled in the same flight and were seated in rows 52 to 58 are urged to call the hotline at 1800-333 9999 to enable the MOH to check on their health condition. The MOH adds that all medical practitioners and healthcare institutions should continue to be vigilant to suspect cases. Singapore will continue with temperature screening for passengers entering Singapore at all checkpoints (land, sea and air). All passengers passing through or entering Singapore are given Health Alert Notices on board their flights, advising them to monitor their own health if they have been to affected areas and to seek medical attention immediately if they are not well.
darren_t Newbie Total Posts: 24	posted Thu 28 May 2009 10:58 AM well it was only a matter of time lah. I mean our neighbours all got it already... but **** suay.. now I will feel even more nervous whenever anyone around me sneezes or coughs
AppleDon Member Total Posts: 93	posted Thu 28 May 2009 04:59 PM she's an SMU student. anyboddy's friend here? how's she doing?
hotbull Very Senior Member Total Posts: 955	posted Thu 28 May 2009 09:28 PM Bad news. Singapore has confirmed three more cases of Influenza A (H1N1). This brings the number of infected persons in the country to four.
AppleDon Member Total Posts: 93	posted Sun 31 May 2009 01:18 PM It seems that the virus is milder than SARS. At least people dying from it is not so common outside Mexico.
hotbull Very Senior Member Total Posts: 955	posted Sun 31 May 2009 05:36 PM We've got a 5th case. SINGAPORE: Singapore on Sunday confirmed its fifth case of the H1N1 virus. The patient is a 22- year-old Singaporean who had travelled to the United States from May 13 to 28. The Health Ministry (MOH) said she is currently being treated at the Communicable Disease Centre at Tan Tock Seng Hospital and is in a stable condition. She returned from New York via Tokyo at about 11.30pm on Friday, on All Nippon Airways NH901 flight, seated at Row 36. She had no fever and passed the thermal scanners at the airport. She was met by her family who took her home in the family car. She subsequently developed a fever at around 8am on Saturday. Her mother drove her to the hospital's emergency department and she was admitted to the Communicable Disease Centre for further testing. Laboratory results confirmed her infection at 8.05pm on the same day. The Ministry said her symptoms are mild.
tigerdeer Very Senior Member Total Posts: 465	posted Tue 02 Jun 2009 08:53 AM The latest is 2 more confirmed cases in SG.
hotbull Very Senior Member Total Posts: 955	posted Tue 02 Jun 2009 11:46 PM It's getting rampant. Singapore has confirmed its 8th H1N1 case today. According to an announcement from the Ministry of Health, the latest case is a 15-year-old male student who is studying in India. He travelled from India to Orlando and Atlanta on a school trip from 17 to 31 May 09. He returned to Singapore from Atlanta via Mumbai on Singapore Airlines SQ421 (Seat 39K) on 1 Jun 09 at 7.36pm. The patient felt feverish during the flight, and his fever was picked up by the thermal scanner at Changi Airport. He was sent to Tan Tock Seng Hospital via 993 ambulance, and subsequently warded at KK Hospital in the early hours of 2 Jun 09. The Ministry also said in its statement that contact tracing of all previous cases, except the seventh case involving a 30-year-old Australian male tourist, and the most recent case, have been accounted for.
hotbull Very Senior Member Total Posts: 955	posted Wed 03 Jun 2009 07:49 PM 9th case today. Singapore has confirmed its ninth Influenza A(H1N1) case. The patient is a 19-year-old Singaporean studying in the United States, who returned for the summer holidays. She arrived in Singapore from New York via Tokyo on All Nippon Airways NH901 at 11:40pm local time on May.
hotbull Very Senior Member Total Posts: 955	posted Thu 04 Jun 2009 05:47 PM It's not stopping. The 10th and 11th patients were on the same flight as the 7th confirmed case, a 30-year-old Australian male tourist who was seated at row 54 on Singapore Airlines SQ25, which arrived in Singapore from New York via Frankfurt at 06:18 hours on June 1. The 10th patient is a 33-year-old Singaporean woman who took a taxi to Tan Tock Seng Hospital after developing symptoms. She was in New York from May 23-30 and was seated at row 19 on SQ25. The 11th patient is an 18-year-old American woman. She was seated at row 57 on SQ25. She developed symptoms in the afternoon of June 2, took a taxi with her relative to seek medical attention at Raffles Hospital's Emergency Department in the evening and was sent to CDC, TTSH via a 993 ambulance.
lame_chop Very Senior Member Total Posts: 358	posted Thu 04 Jun 2009 10:08 PM It's interesting to note that the 10th patient was seated rather far away from the 7th patient. This shows that there is a possibility of spreading the virus to every one in the aircraft. I wonder if it's enough to just notify the passengers seated in the vicinity of the H1N1 carrier. The air in the aircraft circulates throughout the fuselage. Chances of passengers getting the virus when there's a carrier on board are substantial, especially on long-haul flights such as from NY to Tokyo.
hotbull Very Senior Member Total Posts: 955	posted Thu 04 Jun 2009 10:57 PM I think the cases just won't stop. Singapore has confirmed its 12th case of Influenza A (H1N1). The patient is an 18-year-old Singaporean. He went to Melbourne on May 16 and returned on June 1 on Emirates EK405 at 11.50pm. He was seated at row 18.
hotbull Very Senior Member Total Posts: 955	posted Fri 05 Jun 2009 11:54 PM Guys I'm losing count. IS the virus still managable? The Ministry of Health has confirmed another two H1N1 flu cases, bringing to 14 the total number of cases so far. The 13th case is a 23-year-old Singaporean man who went to Melbourne on May 27 and developed symptoms in the early hours of June 3 while he was still there. He returned on Singapore Airlines SQ 238 (Row 40) on June 4. The 14th patient is a 22-year-old Singaporean woman who is a cabin crew with Singapore Airlines. She was on the same SQ 25 flight from New York to Frankfurt as three earlier confirmed cases.
hotbull Very Senior Member Total Posts: 955	posted Sun 07 Jun 2009 01:08 AM Case 15. The latest case is a 39-year-old Indonesian woman who is the aunt of an earlier case. She went to Changi Airport to fetch her niece who returned from New York via Frankfurt on Monday. When the niece developed symptoms on Tuesday, the aunt brought her to Raffles Hospital by taxi.
hotbull Very Senior Member Total Posts: 955	posted Tue 09 Jun 2009 04:36 PM Case 16 & 17. - 40-year-old man from India who works in Singapore. He returned to Singapore from Melbourne, where he was on a business trip, on Singapore Airlines SQ238 on June 6. - 25-year-old air stewardess who was off-duty. The Malaysian was on holiday in Melbourne and returned to Singapore on Emirates EK 405 on June 7.
hotbull Very Senior Member Total Posts: 955	posted Fri 12 Jun 2009 09:12 AM Case 19, 20, 21. The 19th case is a 21-year-old woman who is a Singapore permanent resident studying in Melbourne. The 20th case is a 17-year-old Singaporean who returned to Singapore from Los Angeles via Hong Kong on Cathay Pacific Airways CX717 on June 7. The 21st case is a 21-year-old Indonesian studying in Australia. He came to Singapore from Melbourne on Singapore Airlines SQ228 on June 9.
pinebabe Very Senior Member Total Posts: 902	posted Sun 14 Jun 2009 02:31 PM The no. of cases jumped so much within a week! Singapore confirmed seven more cases of Influenza A (H1N1), bringing the total number of confirmed cases here to 34. It seems like most cases originate out of Melbourne. Hold your travel plans people! And hotbull, I think you are losing count.
Genesis09 Member Total Posts: 132	posted Mon 15 Jun 2009 02:18 PM The increasing rate is terrible but I think it is "good" news for some temp job student.. there is currently an increase amount of temperature screening job all over singapore and I just heard my friend got a pay rise to make them commit for a longer period
hotbull Very Senior Member Total Posts: 955	posted Mon 15 Jun 2009 04:06 PM Oh really? Who do I contact if I want a temp screening job? 40 cases now. Singapore has confirmed another six cases of the H1N1 flu, bringing the total to 40. Three of them are children, aged seven to nine. One of them, a nine-year-old Malaysian boy, had gone to Sydney and Melbourne before coming here for a holiday. Another child, a seven-year-old girl from Australia, also flew in from Melbourne on Saturday, on Singapore Airlines SQ228. The third child, an eight-year-old Singapore permanent resident, had gone to the Philippines for a family visit on May 30, and returned on Saturday. Her mother, who was with her, has also been admitted. The fifth case is a 24-year-old Singaporean off-duty air stewardess who had flown in from Frankfurt on Singapore Airlines SQ25 on June 12. The final case is a 19-year-old Singaporean, returning from his holiday in Melbourne on June 12. Of the 40 cases so far, 19 had travelled to Melbourne, and another 14 had come from the US.

[HenryN]

All of the initial confirmed cases in Singapore are detailed at the MOH website. The only 28F is the patient listed in the first post of this thread

http://www.moh.gov.sg/mohcorp/pressreleases.aspx

First confirmed case of Influenza A (H1N1-2009) in Singapore

27 May 2009

Singapore has confirmed its first case of Influenza A (H1N1-2009). The patient is currently being treated at the Communicable Disease Centre at Tan Tock Seng Hospital (TTSH) and is in stable condition.

3 more confirmed cases of Influenza A (H1N1-2009) in Singapore 28 May 2009 Singapore has confirmed three more cases of Influenza A (H1N1-2009). The patients are currently being treated at the Communicable Disease Centre at Tan Tock Seng Hospital (TTSH). Their symptoms are relatively mild and all of them are in stable condition. The second confirmed case is a 43-year-old female Singapore Permanent Resident who returned to Singapore from San Francisco via Manila on Tuesday, 26 at 1750 hrs. She was on Singapore Airlines, SQ 917 and was seated at 33H. She became unwell while on board. The third confirmed case is a 28-year-old American female who is working in Singapore. She returned to Singapore from Honolulu via Tokyo on Tuesday, 26 May at 2353 hrs, on United Airlines, UA 803. She was seated at 33C. She became unwell on 26 May. The fourth confirmed case is a 28-year-old Singaporean male who returned to Singapore from Chicago via Hong Kong on 25 May at 0036hrs. He was on United Airlines, UA 895 and was seated at 55H. He became unwell on 25 May.

.

[HenryN]

Update On The H1N1 Cases And Progress Of Contact Tracing

31 May 2009

As of 31 May 1500hrs , MOH has served 82 HQOs to close contacts of the five H1N1 confirmed cases. All the five patients have relatively mild symptoms and are doing well. Three of them have been discharged today. All their close contacts on HQO are also reported to be well and have been given Tamiflu as chemoprophylaxis. Update on First Case 2 The 22-year old female SMU student is into the fifth day of Tamiflu treatment at CDC. She is well and in stable condition. Update on Second, Third and Fourth Cases 3 For the above cases, they have been discharged from CDC today as they have been cleared of H1N1 virus. They are now on medical leave. MOH has accounted for all the close contacts of the above three H1N1 confirmed cases in Singapore. To date we have established a total of 131 close contacts comprising 121 flight passengers and 10 local contacts. We have issued 45 HQO to the 53 flight passengers who are in Singapore. We have provided ICA with the details of the 8 remaining passengers. 68 flight passengers were already out of Singapore. 4 For Case 2 involving the 28-year-old Singaporean male who travelled on UA 895 on 25 May 09, MOH has established 66 close contacts comprising 65 flight passengers and one local contact (his wife). 24 were identified for quarantine, of whom 13 are Singaporeans and 11 are foreigners. We are still contacting 5 others, while remaining 37 contacts are out of Singapore. 5 For Case 3 involving the 28-year-old American female expatriate who travelled on UA 803 on 26 May, we have established 23 close contacts comprising 20 flight passengers and three local contacts. Of the three local contacts, two were from her household, and one from the workplace. 11 were identified for quarantine, of whom two are Singaporeans and nine are foreigners. We are still contacting 3 others. The remaining 9 contacts are out of Singapore. 6 For Case 4 involving a 43-year-old female Singapore Permanent Resident who travelled on SQ 917 on 26May 09, we have established 42 close contacts comprising 36 flight passengers and six local contacts. The six local contacts consist of the patient’s friend and five colleagues. 20 were identified for quarantine, of whom nine are Singaporeans while 11 are foreigners. The remaining 22 contacts are out of Singapore. Contact Tracing is on-going for fifth case 7 Contact tracing of all the close contacts of the fifth case , involving the 22- year-old Singaporean female who has a travel history to the USA from 13 – 28 May (Vermont and New York), is still in progress. MOH has so far identified 20 close contacts comprising 5 family members who are local contacts and 15 passengers who are close contacts on the flight. Her 5 family members, who are local contacts, are currently well and will be placed under HQO. Their HQO will end on 6 June. Of the 15 passengers, MOH has so far managed to contact 4 of them and HQOs will be served to them. Their HQO will end on 6 June. Five passengers are known to be outside Singapore.

[HenryN]

Update on confirmed cases of Influenza A (H1N1-2009) in Singapore

29 May 2009

As of 29 May 1100hrs, MOH has served 31 HQOs to close contacts of the four H1N1 confirmed cases. All the 4 patients have relatively mild symptoms and are doing well, and are expected to recover uneventfully. All their close contacts on HQO are also reported to be well and have been given Tamiflu as chemoprophylaxis. Case 1 – 22-year-old female SMU student 2 She is into the third day of Tamiflu treatment. Her fever has subsided and she is in a stable condition. Her friend (who fetched her from the airport and to the GP) has been cleared of H1N1 infection. He was discharged last night and placed on home quarantine. 3 All her close contacts, comprising 71 on-flight contacts and two local contacts have been accounted for. HQOs have been served on 25 close contacts, 10 of them are Singaporeans and 15 of them are foreigners. Their HQOs will expire on 2 Jun. The remaining 48 close contacts are not in Singapore. Case 2 – 28-year-old Singaporean male 4 He returned to Singapore from Chicago via Hong Kong on flight United Airlines 895 on 25 May 0036 hrs. He became unwell on 25 May after arrival, and sought medical attention at a GP clinic on the same day. As he was given an MC, he stayed at home the whole day on 26 May. On 27 May afternoon, he consulted the same GP clinic again and was referred to TTSH via a 993 ambulance. Apart from his two visits to the GP clinic and to TTSH, he remained at home the entire period after arriving back in Singapore. He was admitted to CDC for further assessment on 27 May night. Laboratory results confirmed his infection at 1610 hours on 28 May. His wife has been placed under HQO and is currently well. Her HQO will end on 3 June. Case 3 – 28-year-old American female expatriate 5 She returned to Singapore on flight United Airlines 803 from Honolulu via Tokyo on 26 May 2353 hrs. She became unwell while on board and passed through the thermal scanner at the airport as she did not have a fever then. She was referred by her company doctor to TTSH for assessment on 27 May afternoon via a 993 ambulance. Laboratory results confirmed her infection at 1610 hours on 28 May. 6 HQOs have been served on two local close contacts - her friend and her maid. Both contacts are currently well. Their HQOs will expire on 3 June. Case 4 – 43-year-old female Singapore PR 7 She returned to Singapore from San Francisco via Manila on flight Singapore Airlines SQ917 on 26 May 1750 hrs. She became unwell while on board and passed through the thermal scanner at the airport as she did not have a fever then. She consulted a GP on 27 May around noon and was referred to TTSH. As she did not have a fever at that time, she was advised to put on a mask and to take a cab to TTSH. She was admitted to CDC for further assessment that night. Laboratory results confirmed her infection at 1400 hours on 28 May. 8 HQOs have been served on her local close contacts - her friend and two office colleagues. Their HQOs will expire on 3 Jun. Contact Tracing is on-going 9 Contact tracing for all the close contacts of the latest three confirmed cases is still in progress. MOH has so far identified 122 passengers on the three flights who are close contacts of the latest three confirmed cases. Only half of these passengers (61 passengers) entered Singapore. We have so far managed to contact 18 of them and HQOs will be served to them. 10 Passengers within the first three and back rows of the cases who have not been contacted by MOH yet should call the MOH hotline at 1800-333 9999 to enable us to check on their health condition expeditiously. The affected rows for SQ917 on 26 May are 30-36; for UA803 on 26 May, the affected rows are 30-36 and for UA895 on 25 May, the affected rows are 52-58.

[HenryN]

Fifth Confirmed Case of Influenza A(H1N1-2009)

31 May 2009

1 Singapore has confirmed its fifth case of Influenza A (H1N1-2009). The patient is a 22- year-old Singaporean female who has a travel history to the USA from 13 – 28 May (Vermont and New York). She returned to Singapore from New York via Tokyo on All Nippon Airways NH901 at 2332 hours on 29 May. She was seated at row 36. She passed the thermal scanner uneventfully as she did not have fever. She was met by her family and returned home in the family car. She subsequently developed a fever at around 0800 hours on 30 May. Her mother drove her from home to TTSH ED later that morning. She was admitted to CDC for further assessment in the early afternoon and laboratory results confirmed her infection at 2005 hours on 30 May. 2 Her symptoms are mild and she is in stable condition. MOH has initiated contact tracing of her close contacts, including the passengers on the same flight. They will be quarantined and provided with antiviral prophylaxis. 3 Based on MOH’s risk assessment passengers within rows 34 to 38 on All Nippon Airways NH901 on 29 May who have not been contacted by MOH yet should call the MOH hotline at 1800-333 9999 to enable us to check on their health condition expeditiously.

[HenryN]

Two Additional Confirmed Cases of Influenza A (H1N1-2009) and

01 Jun 2009

6th and 7th Confirmed Cases of Influenza A (H1N1-2009) Singapore has confirmed its 6th and 7th cases of Influenza A (H1N1-2009). Both of them have relatively mild symptoms and are in stable condition. 2 The 6th case is a 36-year-old Singaporean male who was in Manila on a business trip from 18 - 29 May. He returned to Singapore from Manila on Friday 29 May on Singapore Airlines SQ917 at 1750 hours. He was seated at row 17. He went home by taxi and remained home for the rest of the day. On 30 May, he went out briefly in the morning and returned home in the afternoon. He developed symptoms in the evening, and stayed home the whole of the next day. On 1 Jun morning, he called a 993 ambulance to take him to TTSH for further assessment. Laboratory results confirmed his infection at 1440 hours on 1 June and he was admitted to CDC. 3 The 7th case is a 30-year-old Australian male tourist who had travelled to Chicago from 14 - 21 May, Detroit from 21 - 25 May, and New York from 25 - 30 May. He developed symptoms on 26 May while he was in New York. He arrived in Singapore from New York via Frankfurt on SQ25 at 0618 hours on 1 June. He was seated at row 54. He went straight to Raffles Medical Group clinic at Changi Airport transit area upon arrival, and was sent to TTSH via a 993 ambulance. He was admitted to CDC for further assessment in the late morning. Laboratory results confirmed his infection at 1645 hours on 1 June. 4 MOH is currently reviewing the 6th case. It appears that he was well during the flight which was more than 24 hours before onset of his symptoms. He has informed MOH that a passenger who was seated next to him appeared unwell and was coughing during the flight. MOH is trying to identify the ill passenger to assess his health condition. Contact tracing has been initiated for the close local contacts of the 6th case who will be quarantined and provided with antiviral prophylaxis. 5 MOH has initiated contact tracing of the close contacts of the 7th case. They will be quarantined and provided with antiviral prophylaxis. Based on MOH’s risk assessment, passengers within rows 52 to 56 on SQ25 on 1 Jun who have not been contacted by MOH yet should call the MOH hotline at 1800-333 9999 to enable us to check on their health condition expeditiously.

[HenryN]

8th Confirmed Case of Influenza A (H1N1-2009)

02 Jun 2009

Singapore has confirmed its 8th case of Influenza A (H1N1-2009). The patient is a 15-year-old Singaporean male who is studying in India. He travelled from India to Orlando and Atlanta on a school trip from 17 to 31 May 09. He returned to Singapore from Atlanta via Mumbai on Singapore Airlines SQ421 (Seat 39K) on 1 Jun 09 at 1936hrs. He was feverish during the flight, and his fever was picked up by the thermal scanner at Changi Airport. He was sent to TTSH via 993 ambulance, and subsequently warded at KKH in the early hours of 2 Jun 09. Laboratory results confirmed his infection at 1440hrs on 2 Jun 09. 2. Contact tracing of his close contacts are ongoing. Passengers within rows 37 to 41 on SQ421 on 1 Jun 09 who have not been contacted by MOH yet should call the MOH hotline at 1800-333 9999 to enable us to check on their health condition expeditiously. All close contacts indentified will be quarantined and provided with antiviral prophylaxis. Contact tracing for previous confirmed cases 3. Contact tracing of all previous cases, except the seventh case involving a 30-year-old Australian male tourist, have been accounted for. All 28 closed contacts of the first case, involving the 22-year-old SMU female student who was in New York from 14- 24 May 09, have discharged their HQOs today and are all well. 4. For the 6th case involving the 36-year-old Singaporean male who was in Manila on a business trip from 18-29 May, MOH has identified 3 close contacts involving the case’s family members. They are currently well and HQOs will be served to them. No flight passengers need to be quarantined as the case only developed onset of symptoms more than 24 hours after disembarkation, and hence the patient was assessed to be non-infectious during the flight. 5. For the 7th case involving the 30-year-old Australian male tourist, contact tracing for flight passengers is still on going. As the case is a foreigner who was sent direct from Changi Airport to TTSH via a 993 ambulance, there were no local contacts. Passengers within rows 52 to 56 on SQ25 on 1 June who have not been contacted by MOH yet should call the MOH hotline at 1800-333 9999 to enable us to check on their health condition expeditiously.

[HenryN]

10th and 11th Confirmed Case of Influenza A (H1N1-2009) and Changes to the list of affected areas

03 Jun 2009

Singapore has confirmed its 10th and 11th cases of Influenza A (H1N1-2009). Both patients were on the same flight - Singapore Airlines SQ25 from New York via Frankfurt on 1 Jun - as the 7th confirmed case, a 30-year-old Australian male tourist who was seated at Row 54. The flight arrived in Singapore at 0618 hours on 1 June. The 10th confirmed case 2 The patient is a 33-year-old Singaporean female who was in New York from 23 - 30 May. She was seated at row 19 on SQ25. She went home by taxi from the airport and developed symptoms later in the same morning. She remained home for the rest of the day. On 2 June, she stayed at home the whole day and in the evening, took a taxi to TTSH. She was admitted to CDC2, TTSH before midnight on 2 June. The 11th confirmed case 3 The patient is an 18-year old American female visitor. She was seated at row 57. She was met by her relative at the airport and they took a taxi to the relative's residence. She developed symptoms in the afternoon of 2 June, took a taxi with her relative to seek medical attention at Raffles Hospital’s Emergency Department in the evening and was sent to CDC, TTSH via a 993 ambulance. She was admitted to CDC2 in the early hours on 3 June. 4 Laboratory results confirmed their infection at 1500 hours on 3 June. Contact tracing 5 Contact tracing has been initiated for the 10th and 11th confirmed cases. Based on MOH’s risk assessment, passengers within rows 17 to 21 and rows 57 to 59 (passengers in rows 55-56 have already been contacted in relation to the 7th confirmed case) on SQ 25 on 1 June who have not been contacted by MOH yet should call the MOH hotline at 1800-333 9999 to enable us to check on their health condition expeditiously. 6 For the 9th case involving a 19-year-old Singaporean female who arrived in Singapore from New York on 28 May, MOH has identified 2 household contacts for HQOs. They are currently well. Contact tracing is still on-going for any other close contacts.

[HenryN]

9th Confirmed Case of Influenza A (H1N1-2009)

03 Jun 2009

Singapore has confirmed its 9th case of Influenza A (H1N1-2009). The patient is a 19-year-old Singaporean female studying in USA who returned for the summer holidays. She arrived in Singapore from New York via Tokyo on All Nippon Airways NH901 at 2340 hours on 28 May. She developed symptoms in the morning of 1 June, and a 993 ambulance was called to send her to the Communicable Disease Centre at TTSH. She was admitted to CDC in the afternoon of 1 June. Laboratory results confirmed her infection at 2100 hours on 2 June. 2 MOH has assessed that no flight passengers needed to be quarantined as the case only developed onset of symptoms more than 24 hours after disembarkation, hence she was assessed to be non-infectious during the flight. 3 Tracing for the local contacts has been initiated. So far, we have identified 2 close contacts involving the case’s family members. They are currently well and HQOs will be served to them. Tracing for other local contacts is on-going. 4 So far, all the 9 cases are imported and have a travel history. There is currently no evidence of community spread. MOH is monitoring the situation closely and will update the public on any new developments. For more information on Influenza A (H1N1-2009), please access MOH’s website at www.moh.gov.sg, call our hotline at 1800-333 9999, or visit www.flu.gov.sg.

[HenryN]

12th Confirmed Case of Influenza A (H1N1-2009)

04 Jun 2009

Singapore has confirmed its 12th case of Influenza A (H1N1-2009). The patient is an 18-year-old Singaporean male. He went to Melbourne on 16 May and returned to Singapore on Emirates EK405 on 1 June at 2350 hours. He was seated at row 18. He was sent to TTSH ED at about 12 noon today by ambulance via 993. Laboratory results confirmed his infection at 1925 hours on 4 June and he was admitted to the Communicable Disease Centre. 2 Contact tracing is ongoing for the 12th confirmed case. MOH will provide more information when it is available.

[HenryN]

Commentary

http://www.recombinomics.com/News/08...re_Hawaii.html

[AlaskaDenise]

Originally Posted by niman

Commentary

http://www.recombinomics.com/News/08...re_Hawaii.html

Commentary

First Tamiflu Resistant Pandemic H1N1 - Singapore ex-Hawaii

Recombinomics Commentary 20:09
August 9, 2009

The third confirmed case is a 28-year-old American female who is working in Singapore. She returned to Singapore from Honolulu via Tokyo on Tuesday, 26 May at 2353 hrs, on United Airlines, UA 803. She was seated at 33C. She became unwell on 26 May.

She returned to Singapore on flight United Airlines 803 from Honolulu via Tokyo on 26 May 2353 hrs. She became unwell while on board and passed through the thermal scanner at the airport as she did not have a fever then. She was referred by her company doctor to TTSH for assessment on 27 May afternoon via a 993 ambulance. Laboratory results confirmed her infection at 1610 hours on 28 May.

For the above cases, they have been discharged from CDC today as they have been cleared of H1N1 virus. They are now on medical leave.

The above descriptions match the patient linked to the recently released NA sequence, A/Singapore/57/2009, by the CDC at GISAID. Although the sequence represents the earliest reported case of H274Y in pandemic H1N1, it was released without fanfare on Thursday. Media reports (see Singapore map) contained the information in the first paragraph above. This information, and the additional information described in Singapore MOH press releases, indicate the case was mild and made no mention of Tamiflu treatment, consistent with the short course and discharge on May 31.

The characterization sheet indicates isolation was on May 30 from a 28 year old female, which is consistent with the above information. The first confirmed case in Singapore was on May 26, and above patient was the third confirmed case. It is the only patient matching age and gender, indicating she is the source of A/Singapore/57/2009. Since she developed symptoms while in flight, the infection was likely from a contact in Honolulu, which is similar to the history of the American traveler from San Francisco. She also had a mild case and refused Tamiflu, but recovered quickly. Although media reports indicated she had a fever when she landed, Hong Kong reports suggested she was asymptomatic at landing, but tested positive shortly thereafter. Thus, infections in both passengers were confirmed in countries in Asia, but infections were in the United States, where there have been no reported cases of Tamiflu resistance.

The export of Tamiflu resistance in the absence of detection in the United States sends a strong signal of a flawed surveillance system. Since both of these cases were mild, yet involved a fit H1N1 with H274Y, the failure to detect similar cases in California or Hawaii may be due to an emphasis on testing more severe cases. The decision to ignore and not report mild cases creates an environment for silent spread of the H1N1 as well as the associated Tamiflu resistance.

Moreover, the release of the sequence in August from a patient infected in April, raises concerns of more such examples in samples collected, but not sequenced, analyzed, or reported. These concerns have been heightened by the frequent detection of H274Y in patients receiving prophylactic Tamiflu, which would be among those most easily identified, as well as additional reports of resistance in China and Thailand, which lack information on the Tamiflu treatment status of the patients or in the case of Thailand, the sample collection date. The sample in China was collected on June 13, again signaling a long delay between sample collection and release of the associated sequences, suggesting that these patients were also not taking Tamiflu, and sequencing of these milder cases has a low priority or a large backlog.

The resistance in patients in Singapore, China, and Thailand released this week adds to concerns associated with the prior Tamiflu resistance cases in Denmark, Japan, Canada and Hong Kong (ex San Francisco), which support silent spread of Tamiflu resistance worldwide.

.

[Mamabird]

Well, it can be a silent spread, or it can be a well monitored noisy spread, but after all is said and done, it will continue to spread nonetheless.

[HenryN]

Originally Posted by Mamabird

Well, it can be a silent spread, or it can be a well monitored noisy spread, but after all is said and done, it will continue to spread nonetheless.

Yes, it will continue, but most have no clue.

[HenryN]

Originally Posted by Mamabird

Well, it can be a silent spread, or it can be a well monitored noisy spread, but after all is said and done, it will continue to spread nonetheless.

While it will continue to spread, a media myth has been created so MD's believe resistance is rare. As a result, patients in trouble are treated with Tamiflu, leading to more problems. So the key question is whether the media myth on Tamiflu resistance is driving the increasing death toll.

[Mamabird]

Originally Posted by niman

While it will continue to spread, a media myth has been created so MD's believe resistance is rare. As a result, patients in trouble are treated with Tamiflu, leading to more problems. So the key question is whether the media myth on Tamiflu resistance is driving the increasing death toll.

The physicians with which I work have long been concerned with the inappropriate use of Tamiflu, and CDC guidance on the use of antivirals also attempts to keep all on track.

However, it's probably a bit late to attempt to turn things completely around. We will likely continue to see increased resistance, basically in the same manner as Seasonal H1N1. It's just a matter of time.

[HenryN]

Originally Posted by Mamabird

The physicians with which I work have long been concerned with the inappropriate use of Tamiflu, and CDC guidance on the use of antivirals also attempts to keep all on track.

However, it's probably a bit late to attempt to turn things completely around. We will likely continue to see increased resistance, basically in the same manner as Seasonal H1N1. It's just a matter of time.

I agree that the spread will continue, but I think patients are needlessly dying because Tamiflu remains the first treatment choice for SERIOUS cases (which are the patients who are dying or getting hospitaltized).

[HenryN]

Updated H274Y travel log

gb|GQ463202.1| Influenza A virus (A/Hunan/SWL3/2009(H1N1)) se... 34.2 2.9
gb|CY043352.1| Influenza A virus (A/Denmark/528/2009(H1N1)) s... 34.2 2.9
gb|GQ397279.1| Influenza A virus (A/Yamaguchi/22/2009(H1N1)) ... 34.2 2.9
gb|GQ365445.1| Influenza A virus (A/Osaka/180/2009(H1N1)) seg... 34.2 2.9
gb|GQ351316.1| Influenza A virus (A/Hong Kong/2369/2009(H1N1)... 34.2 2.9
gb|EU567011.1| Influenza A virus (A/Indiana/01/2008(H1N1)) se... 34.2 2.9
gb|DQ493078.1| Influenza A virus (A/Vietnam/CL2009/2005(H5N1)... 34.2 2.9
gb|DQ250165.1| Influenza A virus (A/Vietnam/CL2009/2005(H5N1)... 34.2 2.9

[Laidback Al]

Originally Posted by niman

I agree that the spread will continue, but I think patients are needlessly dying because Tamiflu remains the first treatment choice for SERIOUS cases (which are the patients who are dying or getting hospitaltized).

I assume you are referring to the fact that by the time they are seriously ill or hospitalized it is too later for Tamiflu to be effective.

[HenryN]

Originally Posted by Laidback Al

I assume you are referring to the fact that by the time they are seriously ill or hospitalized it is too later for Tamiflu to be effective.

No. What I am saying is that physicians assume that resistance may very well happen in the future, but think that currently, there is little, so they treat at risk patients with Tamiflu (patients with underlying conditions that place then at risk for complications). These patients don't respond (or briefly respond) and then become too ill for any antiviral to be effective.

[HenryN]

Singapore confirms first Tamiflu-resistant A/H1N1 case

www.chinaview.cn 2009-08-15 07:43:41

Print

SINGAPORE, Aug. 14 (Xinhua) -- Singapore's Ministry of Health on Friday confirmed that the country has found its first Tamiflu-resistant A/H1N1 case. A Health Ministry spokesperson said that the isolated case involved a patient who fell sick towards the end of May and was admitted to hospital for isolation and treatment. The patient was infected by a Tamiflu-susceptible strain of the virus and treated with Tamiflu. The resistant strain emerged during treatment and was detected through laboratory testing but by then the patient had already improved clinically. "Patients can recover from their illness even if they are infected with a Tamiflu-resistant influenza strain because the immune system plays an important part in clearing the body of the virus," the spokesperson said. The spokesperson did not reveal the age and gender of the patient. "So far, we have not detected any other cases of antiviral resistance. We will continue to conduct surveillance for antiviral resistance," the spokesperson said. Singapore reported its first confirmed case of flu A/H1N1 on May 27. The country's first A/H1N1 related death case was reportedon July 18. The country has reported 11 A/H1N1 related death cases so far. http://news.xinhuanet.com/english/20...t_11884727.htm

[HenryN]

GGTTGATGATGGTTT
gb|CY044080.1| Influenza A virus (A/New York/3715/2009(H1N1))... 28.3 1.2
gb|CY044072.1| Influenza A virus (A/New York/3702/2009(H1N1))... 28.3 1.2
gb|CY042320.1| Influenza A virus (A/swine/Illinois/Sg-00445/2... 28.3 1.2
gb|CY042316.1| Influenza A virus (A/swine/Illinois/Sg-00444/2... 28.3 1.2
gb|CY042312.1| Influenza A virus (A/swine/Illinois/Sg-00443/2... 28.3 1.2
gb|GQ414768.1| Influenza A virus (A/Sao Paulo/43812/2009(H1N1... 28.3 1.2
gb|GQ377095.1| Influenza A virus (A/California/24/2009(H1N1))... 28.3 1.2
gb|GQ359765.1| Influenza A virus (A/Stockholm/31/2009(H1N1)) ... 28.3 1.2
gb|GQ292961.1| Influenza A virus (A/Mexico City/22/2009(H1N1)... 28.3 1.2
gb|GQ229365.1| Influenza A virus (A/swine/Hong Kong/NS623/200... 28.3 1.2
gb|GQ229357.1| Influenza A virus (A/swine/Hong Kong/9656/2001... 28.3 1.2
gb|GQ229348.1| Influenza A virus (A/swine/Hong Kong/NS857/200... 28.3 1.2
gb|GQ229333.1| Influenza A virus (A/swine/Hong Kong/1562/2005... 28.3 1.2
gb|GQ229293.1| Influenza A virus (A/swine/Hong Kong/NS1659/20... 28.3 1.2
gb|GQ229269.1| Influenza A virus (A/swine/Hong Kong/915/2004(... 28.3 1.2
gb|GQ229261.1| Influenza A virus (A/swine/Hong Kong/NS837/200... 28.3 1.2
gb|GQ232085.1| Influenza A virus (A/Guangdong/02/2009(H1N1)) ... 28.3 1.2
gb|GQ223435.1| Influenza A virus (A/Guangdong/05/2009(H1N1)) ... 28.3 1.2
gb|GQ161163.1| Influenza A virus (A/swine/Granstedt/IDT3475/2... 28.3 1.2
gb|GQ161145.1| Influenza A virus (A/swine/Kitzen/IDT6142/2007... 28.3 1.2
gb|GQ161143.1| Influenza A virus (A/swine/Groitzsch/IDT6016-2... 28.3 1.2
gb|GQ161141.1| Influenza A virus (A/swine/Groitzsch/IDT6016-1... 28.3 1.2
gb|GQ161104.1| Influenza A virus (A/swine/Bakum/1832/2000(H1N... 28.3 1.2
gb|CY040604.1| Influenza A virus (A/swine/North Carolina/9675... 28.3 1.2
gb|CY040603.1| Influenza A virus (A/swine/North Carolina/4871... 28.3 1.2
gb|CY040602.1| Influenza A virus (A/swine/North Carolina/4775... 28.3 1.2
gb|CY040601.1| Influenza A virus (A/swine/North Carolina/4509... 28.3 1.2
gb|CY040600.1| Influenza A virus (A/swine/North Carolina/4488... 28.3 1.2
gb|CY040599.1| Influenza A virus (A/swine/North Carolina/4427... 28.3 1.2
gb|CY040598.1| Influenza A virus (A/swine/North Carolina/3668... 28.3 1.2
gb|CY040597.1| Influenza A virus (A/swine/North Carolina/2969... 28.3 1.2
gb|CY040596.1| Influenza A virus (A/swine/North Carolina/2676... 28.3 1.2
gb|CY040595.1| Influenza A virus (A/swine/North Carolina/9856... 28.3 1.2
gb|CY040594.1| Influenza A virus (A/swine/North Carolina/4511... 28.3 1.2
gb|CY040593.1| Influenza A virus (A/swine/North Carolina/4488... 28.3 1.2
gb|CY040592.1| Influenza A virus (A/swine/North Carolina/4452... 28.3 1.2
gb|CY040591.1| Influenza A virus (A/swine/North Carolina/4350... 28.3 1.2
gb|CY040590.1| Influenza A virus (A/swine/North Carolina/4162... 28.3 1.2
gb|CY040589.1| Influenza A virus (A/swine/North Carolina/3789... 28.3 1.2
gb|CY040588.1| Influenza A virus (A/swine/North Carolina/3527... 28.3 1.2
gb|CY040587.1| Influenza A virus (A/swine/North Carolina/2948... 28.3 1.2
gb|CY040586.1| Influenza A virus (A/swine/North Carolina/1286... 28.3 1.2
gb|CY040578.1| Influenza A virus (A/swine/North Carolina/4257... 28.3 1.2
gb|CY040576.1| Influenza A virus (A/swine/North Carolina/3876... 28.3 1.2
gb|CY040573.1| Influenza A virus (A/swine/North Carolina/2629... 28.3 1.2
gb|CY040571.1| Influenza A virus (A/swine/North Carolina/1286... 28.3 1.2
gb|CY040569.1| Influenza A virus (A/swine/North Carolina/3456... 28.3 1.2
gb|CY040567.1| Influenza A virus (A/swine/North Carolina/901/... 28.3 1.2
gb|CY040565.1| Influenza A virus (A/swine/North Carolina/4613... 28.3 1.2
gb|CY040563.1| Influenza A virus (A/swine/North Carolina/4390... 28.3 1.2
gb|CY040561.1| Influenza A virus (A/swine/North Carolina/2812... 28.3 1.2
gb|CY040559.1| Influenza A virus (A/swine/North Carolina/9647... 28.3 1.2
gb|CY040557.1| Influenza A virus (A/swine/North Carolina/4743... 28.3 1.2
gb|CY040555.1| Influenza A virus (A/swine/North Carolina/4685... 28.3 1.2
gb|CY040553.1| Influenza A virus (A/swine/North Carolina/4620... 28.3 1.2
gb|CY040551.1| Influenza A virus (A/swine/North Carolina/4401... 28.3 1.2
gb|CY040549.1| Influenza A virus (A/swine/North Carolina/4395... 28.3 1.2
gb|CY040547.1| Influenza A virus (A/swine/North Carolina/4311... 28.3 1.2
gb|CY040545.1| Influenza A virus (A/swine/North Carolina/7571... 28.3 1.2
gb|CY040543.1| Influenza A virus (A/swine/North Carolina/7386... 28.3 1.2
gb|CY040541.1| Influenza A virus (A/swine/Texas/36440-2/2005(... 28.3 1.2
gb|CY039991.1| Influenza A Virus (A/New Jersey/8/1976(H1N1)) ... 28.3 1.2
gb|GQ132144.1| Influenza A virus (A/Canada-ON/RV1529/2009(H1N... 28.3 1.2
gb|CY039925.1| Influenza A Virus (A/swine/Indiana/1726/1988(H... 28.3 1.2
gb|CY039917.1| Influenza A Virus (A/swine/Wisconsin/1915/1988... 28.3 1.2
gb|CY039909.1| Influenza A Virus (A/Maryland/12/1991(H1N1)) s... 28.3 1.2
gb|FJ986621.1| Influenza A virus (A/Ohio/02/2007(H1N1)) segme... 28.3 1.2
gb|FJ986620.1| Influenza A virus (A/Ohio/01/2007(H1N1)) segme... 28.3 1.2
gb|FJ986619.1| Influenza A virus (A/Wisconsin/87/2005(H1N1)) ... 28.3 1.2
gb|AY377936.2| Influenza A virus (A/swine/Pingtung/92-2/2003(... 28.3 1.2
gb|EU604689.1| Influenza A virus (A/swine/OH/511445/2007(H1N1... 28.3 1.2
gb|CY036863.1| Influenza A virus (A/swine/Tennessee/107/1977(... 28.3 1.2
gb|CY036799.1| Influenza A virus (A/swine/Wisconsin/30954/197... 28.3 1.2
dbj|AB434416.1| Influenza A virus (A/swine/Saitama/1996(H1N2)... 28.3 1.2
dbj|AB434408.1| Influenza A virus (A/swine/Ehime/1/1980(H1N2)... 28.3 1.2
dbj|AB434400.1| Influenza A virus (A/swine/Niigata/1/1977(H1N... 28.3 1.2
dbj|AB434392.1| Influenza A virus (A/swine/Hokkaido/2/1981(H1... 28.3 1.2
gb|FJ357104.1| Influenza A virus (A/turkey/NC/17026/1988(H1N1... 28.3 1.2
gb|CY035070.1| Influenza A virus (A/swine/Memphis/1/1990(H1N1... 28.3 1.2
gb|CY035030.1| Influenza A virus (A/X-53A(Puerto Rico/8/1934-... 28.3 1.2
gb|EU798784.1| Influenza A virus (A/swine/Korea/Asan04/2006(H... 28.3 1.2
gb|EU798783.1| Influenza A virus (A/swine/Korea/JL04/2005(H1N... 28.3 1.2
gb|EU798781.1| Influenza A virus (A/swine/Korea/JL01/2005(H1N... 28.3 1.2
gb|EU798780.1| Influenza A virus (A/swine/Korea/Hongsong2/200... 28.3 1.2
gb|EU798779.1| Influenza A virus (A/swine/Korea/CAS08/2005(H1... 28.3 1.2
gb|EU743159.1| Influenza A virus (A/turkey/IA/21089-3/1992(H1... 28.3 1.2
gb|EU743175.1| Influenza A virus (A/chicken/NY/21665-73/1998(... 28.3 1.2
gb|CY032929.1| Influenza A virus (A/swine/Tennessee/109/1977(... 28.3 1.2
dbj|AB434384.1| Influenza A virus (A/swine/Kyoto/3/1979(H1N1)... 28.3 1.2
gb|EU735786.1| Influenza A virus (A/turkey/NC/19762/1988(H1N1... 28.3 1.2
gb|EU735794.1| Influenza A virus (A/chicken/PA/35154/1991(H1N... 28.3 1.2
gb|EU742636.1| Influenza A virus (A/turkey/KS/4880/1980(H1N1)... 28.3 1.2
gb|EU409960.1| Influenza A virus (A/swine/Ohio/C62006/06(H1N1... 28.3 1.2
gb|EU409948.1| Influenza A virus (A/swine/Ohio/24366/07(H1N1)... 28.3 1.2
gb|CY030735.1| Influenza A virus (A/swine/Tennessee/9/1978(H1... 28.3 1.2
gb|CY028780.1| Influenza A virus (A/swine/California/T9001707... 28.3 1.2
gb|CY028788.1| Influenza A virus (A/swine/Iowa/1/1986(H1N1)) ... 28.3 1.2
gb|CY028435.1| Influenza A virus (A/swine/Tennessee/7/1978(H1... 28.3 1.2
gb|CY028427.1| Influenza A virus (A/swine/Tennessee/4/1978(H1... 28.3 1.2

[HenryN]

HA travel log of A/Singaore/57/2009

gb|CY044080.1| Influenza A virus (A/New York/3715/2009(H1N1))... 28.3 1.2
gb|CY044072.1| Influenza A virus (A/New York/3702/2009(H1N1))... 28.3 1.2
gb|CY042320.1| Influenza A virus (A/swine/Illinois/Sg-00445/2... 28.3 1.2
gb|CY042316.1| Influenza A virus (A/swine/Illinois/Sg-00444/2... 28.3 1.2
gb|CY042312.1| Influenza A virus (A/swine/Illinois/Sg-00443/2... 28.3 1.2
gb|GQ414768.1| Influenza A virus (A/Sao Paulo/43812/2009(H1N1... 28.3 1.2
gb|GQ377095.1| Influenza A virus (A/California/24/2009(H1N1))... 28.3 1.2
gb|GQ359765.1| Influenza A virus (A/Stockholm/31/2009(H1N1)) ... 28.3 1.2
gb|GQ292961.1| Influenza A virus (A/Mexico City/22/2009(H1N1)... 28.3 1.2
gb|GQ229365.1| Influenza A virus (A/swine/Hong Kong/NS623/200... 28.3 1.2
gb|GQ229357.1| Influenza A virus (A/swine/Hong Kong/9656/2001... 28.3 1.2
gb|GQ229348.1| Influenza A virus (A/swine/Hong Kong/NS857/200... 28.3 1.2
gb|GQ229333.1| Influenza A virus (A/swine/Hong Kong/1562/2005... 28.3 1.2
gb|GQ229293.1| Influenza A virus (A/swine/Hong Kong/NS1659/20... 28.3 1.2
gb|GQ229269.1| Influenza A virus (A/swine/Hong Kong/915/2004(... 28.3 1.2
gb|GQ229261.1| Influenza A virus (A/swine/Hong Kong/NS837/200... 28.3 1.2
gb|GQ232085.1| Influenza A virus (A/Guangdong/02/2009(H1N1)) ... 28.3 1.2
gb|GQ223435.1| Influenza A virus (A/Guangdong/05/2009(H1N1)) ... 28.3 1.2
gb|GQ161163.1| Influenza A virus (A/swine/Granstedt/IDT3475/2... 28.3 1.2
gb|GQ161145.1| Influenza A virus (A/swine/Kitzen/IDT6142/2007... 28.3 1.2
gb|GQ161143.1| Influenza A virus (A/swine/Groitzsch/IDT6016-2... 28.3 1.2
gb|GQ161141.1| Influenza A virus (A/swine/Groitzsch/IDT6016-1... 28.3 1.2
gb|GQ161104.1| Influenza A virus (A/swine/Bakum/1832/2000(H1N... 28.3 1.2
gb|CY040604.1| Influenza A virus (A/swine/North Carolina/9675... 28.3 1.2
gb|CY040603.1| Influenza A virus (A/swine/North Carolina/4871... 28.3 1.2
gb|CY040602.1| Influenza A virus (A/swine/North Carolina/4775... 28.3 1.2
gb|CY040601.1| Influenza A virus (A/swine/North Carolina/4509... 28.3 1.2
gb|CY040600.1| Influenza A virus (A/swine/North Carolina/4488... 28.3 1.2
gb|CY040599.1| Influenza A virus (A/swine/North Carolina/4427... 28.3 1.2
gb|CY040598.1| Influenza A virus (A/swine/North Carolina/3668... 28.3 1.2
gb|CY040597.1| Influenza A virus (A/swine/North Carolina/2969... 28.3 1.2
gb|CY040596.1| Influenza A virus (A/swine/North Carolina/2676... 28.3 1.2
gb|CY040595.1| Influenza A virus (A/swine/North Carolina/9856... 28.3 1.2
gb|CY040594.1| Influenza A virus (A/swine/North Carolina/4511... 28.3 1.2
gb|CY040593.1| Influenza A virus (A/swine/North Carolina/4488... 28.3 1.2
gb|CY040592.1| Influenza A virus (A/swine/North Carolina/4452... 28.3 1.2
gb|CY040591.1| Influenza A virus (A/swine/North Carolina/4350... 28.3 1.2
gb|CY040590.1| Influenza A virus (A/swine/North Carolina/4162... 28.3 1.2
gb|CY040589.1| Influenza A virus (A/swine/North Carolina/3789... 28.3 1.2
gb|CY040588.1| Influenza A virus (A/swine/North Carolina/3527... 28.3 1.2
gb|CY040587.1| Influenza A virus (A/swine/North Carolina/2948... 28.3 1.2
gb|CY040586.1| Influenza A virus (A/swine/North Carolina/1286... 28.3 1.2
gb|CY040578.1| Influenza A virus (A/swine/North Carolina/4257... 28.3 1.2
gb|CY040576.1| Influenza A virus (A/swine/North Carolina/3876... 28.3 1.2
gb|CY040573.1| Influenza A virus (A/swine/North Carolina/2629... 28.3 1.2
gb|CY040571.1| Influenza A virus (A/swine/North Carolina/1286... 28.3 1.2
gb|CY040569.1| Influenza A virus (A/swine/North Carolina/3456... 28.3 1.2
gb|CY040567.1| Influenza A virus (A/swine/North Carolina/901/... 28.3 1.2
gb|CY040565.1| Influenza A virus (A/swine/North Carolina/4613... 28.3 1.2
gb|CY040563.1| Influenza A virus (A/swine/North Carolina/4390... 28.3 1.2
gb|CY040561.1| Influenza A virus (A/swine/North Carolina/2812... 28.3 1.2
gb|CY040559.1| Influenza A virus (A/swine/North Carolina/9647... 28.3 1.2
gb|CY040557.1| Influenza A virus (A/swine/North Carolina/4743... 28.3 1.2
gb|CY040555.1| Influenza A virus (A/swine/North Carolina/4685... 28.3 1.2
gb|CY040553.1| Influenza A virus (A/swine/North Carolina/4620... 28.3 1.2
gb|CY040551.1| Influenza A virus (A/swine/North Carolina/4401... 28.3 1.2
gb|CY040549.1| Influenza A virus (A/swine/North Carolina/4395... 28.3 1.2
gb|CY040547.1| Influenza A virus (A/swine/North Carolina/4311... 28.3 1.2
gb|CY040545.1| Influenza A virus (A/swine/North Carolina/7571... 28.3 1.2
gb|CY040543.1| Influenza A virus (A/swine/North Carolina/7386... 28.3 1.2
gb|CY040541.1| Influenza A virus (A/swine/Texas/36440-2/2005(... 28.3 1.2
gb|CY039991.1| Influenza A Virus (A/New Jersey/8/1976(H1N1)) ... 28.3 1.2
gb|GQ132144.1| Influenza A virus (A/Canada-ON/RV1529/2009(H1N... 28.3 1.2
gb|CY039925.1| Influenza A Virus (A/swine/Indiana/1726/1988(H... 28.3 1.2
gb|CY039917.1| Influenza A Virus (A/swine/Wisconsin/1915/1988... 28.3 1.2
gb|CY039909.1| Influenza A Virus (A/Maryland/12/1991(H1N1)) s... 28.3 1.2
gb|FJ986621.1| Influenza A virus (A/Ohio/02/2007(H1N1)) segme... 28.3 1.2
gb|FJ986620.1| Influenza A virus (A/Ohio/01/2007(H1N1)) segme... 28.3 1.2
gb|FJ986619.1| Influenza A virus (A/Wisconsin/87/2005(H1N1)) ... 28.3 1.2
gb|AY377936.2| Influenza A virus (A/swine/Pingtung/92-2/2003(... 28.3 1.2
gb|EU604689.1| Influenza A virus (A/swine/OH/511445/2007(H1N1... 28.3 1.2
gb|CY036863.1| Influenza A virus (A/swine/Tennessee/107/1977(... 28.3 1.2
gb|CY036799.1| Influenza A virus (A/swine/Wisconsin/30954/197... 28.3 1.2
dbj|AB434416.1| Influenza A virus (A/swine/Saitama/1996(H1N2)... 28.3 1.2
dbj|AB434408.1| Influenza A virus (A/swine/Ehime/1/1980(H1N2)... 28.3 1.2
dbj|AB434400.1| Influenza A virus (A/swine/Niigata/1/1977(H1N... 28.3 1.2
dbj|AB434392.1| Influenza A virus (A/swine/Hokkaido/2/1981(H1... 28.3 1.2
gb|FJ357104.1| Influenza A virus (A/turkey/NC/17026/1988(H1N1... 28.3 1.2
gb|CY035070.1| Influenza A virus (A/swine/Memphis/1/1990(H1N1... 28.3 1.2
gb|CY035030.1| Influenza A virus (A/X-53A(Puerto Rico/8/1934-... 28.3 1.2
gb|EU798784.1| Influenza A virus (A/swine/Korea/Asan04/2006(H... 28.3 1.2
gb|EU798783.1| Influenza A virus (A/swine/Korea/JL04/2005(H1N... 28.3 1.2
gb|EU798781.1| Influenza A virus (A/swine/Korea/JL01/2005(H1N... 28.3 1.2
gb|EU798780.1| Influenza A virus (A/swine/Korea/Hongsong2/200... 28.3 1.2
gb|EU798779.1| Influenza A virus (A/swine/Korea/CAS08/2005(H1... 28.3 1.2
gb|EU743159.1| Influenza A virus (A/turkey/IA/21089-3/1992(H1... 28.3 1.2
gb|EU743175.1| Influenza A virus (A/chicken/NY/21665-73/1998(... 28.3 1.2
gb|CY032929.1| Influenza A virus (A/swine/Tennessee/109/1977(... 28.3 1.2
dbj|AB434384.1| Influenza A virus (A/swine/Kyoto/3/1979(H1N1)... 28.3 1.2
gb|EU735786.1| Influenza A virus (A/turkey/NC/19762/1988(H1N1... 28.3 1.2
gb|EU735794.1| Influenza A virus (A/chicken/PA/35154/1991(H1N... 28.3 1.2
gb|EU742636.1| Influenza A virus (A/turkey/KS/4880/1980(H1N1)... 28.3 1.2
gb|EU409960.1| Influenza A virus (A/swine/Ohio/C62006/06(H1N1... 28.3 1.2
gb|EU409948.1| Influenza A virus (A/swine/Ohio/24366/07(H1N1)... 28.3 1.2
gb|CY030735.1| Influenza A virus (A/swine/Tennessee/9/1978(H1... 28.3 1.2
gb|CY028780.1| Influenza A virus (A/swine/California/T9001707... 28.3 1.2
gb|CY028788.1| Influenza A virus (A/swine/Iowa/1/1986(H1N1)) ... 28.3 1.2
gb|CY028435.1| Influenza A virus (A/swine/Tennessee/7/1978(H1... 28.3 1.2
gb|CY028427.1| Influenza A virus (A/swine/Tennessee/4/1978(H1... 28.3 1.2

[HenryN]

Commentary

[AlaskaDenise]

Originally Posted by niman

Commentary

Commentary

Silent Spread of Tamiflu Resistant Pandemic H1N1 Confirmed

Recombinomics Commentary 14:26
August 15, 2009

A Health Ministry spokesperson said that the isolated case involved a patient who fell sick towards the end of May and was admitted to hospital for isolation and treatment.

The patient was infected by a Tamiflu-susceptible strain of the virus and treated with Tamiflu. The resistant strain emerged during treatment and was detected through laboratory testing but by then the patient had already improved clinically.

The above comments provide additional detail on the first confirmed case of Tamiflu resistance in a swine pandemic H1N1 case. The H274Y was identified in an NA sequence, A/Singapore/57/2009, which was recently deposited by the CDC, along with the HA and MP sequences. All three were clearly from the swine H1N1 pandemic strain, but the presence of H274Y in NA signaled oseltamivir resistance. The sample was from a 28F and was collected May 30, consistent with the description of the above Health Ministry spokesperson.

The MOH website provided a great deal of detail on the initial confirmed cases and contacts. The first confirmed case was May 27, and the third confirmed case matched the description associated with Singapore/57. The only 28F confirned patient ib Singapore in late May / early June was an American who was working in Singapore, She arrived from Honolulu via Tokyo on a flight that arrive just before midnight (23:53) on the night of May 26. Although she did not feel well during the flight, she was not detected by the fever scanners at the airport. However, the next she was transported by ambulance and arrive at the hospital in the afternoon of the 27th, and tested H1N1 positive on the afternoon (16:10) of the 28th.

The NA sequence from the 28th has not been made public, but the comments above indicate the sample was Tamiflu sensitive, It is not clear if treatment began the 27th (upon admission to the hospital), or the 28th, following confirmation of H1N1, because the MOH website does not mention Tamiflu treatment. The patient was described as having a mild case, and was discharged May 31st.

However, the sample collected on May 30th had H274Y, which was 3 days after admission or 2 days after confirmation, indicating the H274Y was silently spreading since it was not detected in the May 28th sample. Detection in the May 30th sample indicates that the H274Y was already present in May 28, but not detected, based on the comments by the spokesperson above, supporting silent spread which is detected in samples collected after Tamiflu treatment.

Although the May 28th sample was Tamiflu sensitive, the May 30th sample had H274Y in the NA sequence, as well as a polymorphism in the HA sequence that was subsequently detected in California and New York in the US, as well as Guangdong Province in China, Mexico City, Stockholm, and the first fatal case in Sao Paulo, Brazil (see list here), raising concerns of silent spread of H274Y worldwide.

The presence of H274Y in a minor species would explain the failure to find H274Y in the above locations, but its presence just below the detection level in untreated patient may explain the recent increases in fatalities. Agencies have repeatedly cited the lack of H274Y detection, leading to the widespread use of Tamiflu in H1N1 in positive cases, including the two imuno-suppressed in the state of Washington, where H274Y was detected for the first time in the United States. In those two patients H274Y was not detected until the patients either had a reoccurrence of symptoms or a failure to respond to treatment. The resistance was found in August, even though both patients developed resistance weeks or months earlier. These detection delays and recent reports of patients, who were resistant in May and June, raise concern that the number of samples with H274Y is significantly higher that the 11 confirmed cases thus far. Media reports have described in at least one patient in Thailand, and earlier media reports described multiple cases in Texas along the Mexican border.

However, the detection of H274Y in the sample collected a few days after the start of treatment in the patient in Singapore suggests the actual incidence is much higher than the reported or withheld cases described by the WHO, and a more intense screening program is critical, especially of samples collected after the start of osletamivir treatment and the increasingly common fatal cases.

.

[HenryN]

http://www.themalaysianinsider.com/i...d-in-singapore

SINGAPORE, Aug 22 — Resistance to Tamiflu has been detected in a patient in Singapore who was down with the pandemic Influenza A (H1N1) bug. Similar cases have also emerged in Hong Kong, China, Japan, Canada, the United States and Denmark.
When the novel strain first appeared in April, the antiviral worked well against it. The World Health Organisation (WHO) feels that these instances of it not working are isolated cases of resistance that have developed because Tamiflu had been used at lower, prophylactic doses in people who might have been exposed to the bug.
Because these so-called contacts were, in fact, already infected, the lower doses turned out to be suboptimal, which allowed resistance to emerge. There is no proof that resistance is circulating in the community at large, the WHO asserts.
Yet there is at least one documented case of a 16-year-old girl who fell ill while travelling from San Francisco to Hong Kong on June 11. Though she declined Tamiflu, an isolate from her was found to carry the H274Y mutation, which signals Tamiflu-resistance.
She was, however, not the world’s first case of such resistance, an honour belonging to a woman seen in Denmark in late June. When she got home from Britain, she was given Tamiflu prophylaxis. Yet she still fell ill on the fifth day of taking Tamiflu. H274Y was detected in her isolate.
Could she have been infected in Britain by someone carrying mainly Tamiflu-sensitive bugs but also a small population of resistant bugs? In that case, suboptimal Tamiflu dosage might have suppressed enough of the sensitive bugs to prevent any clinical symptoms. Over the five days, however, the resistant bugs could have replicated enough to predominate and thus cause clinical illness.
But if this is so, then the mutation must already have been circulating in Britain — which, however, has not reported any cases of Tamiflu resistance yet. Alternatively, she might have caught the resistant bug in Denmark itself, during the five days when she was well and ambulant.
One reason for suspecting community circulation of the resistant bug is that 98 per cent of all seasonal H1N1 bugs now carry H274Y. If patients are infected with both strains, that mutation could jump from seasonal flu to pandemic flu. But the WHO insists there is no evidence this has occurred, so all resistant cases must have emerged because of suboptimal Tamiflu dosages.
There are signs of community circulation in the US, at least. First, the genomics of the Hong Kong isolate where no Tamiflu was used suggests that the infection originated in the US.
Second, it was revealed only this month that a May 30 isolate taken from a young American woman returning to Singapore from Honolulu carried H274Y.
Flying on May 26, she fell ill on board the plane, was hospitalised here on May 27, was confirmed to be a H1N1 case on May 28, but was discharged on May 31 feeling well.
Although her May 28 sample was Tamiflu-sensitive, her May 30 sample had H274Y. Two days is probably too short an interval for resistance to develop from any suboptimal dosages of Tamiflu. At any rate, as a confirmed case, she would have been given the full dosage.
Thus it is entirely possible that she was infected in the US with both the sensitive and resistant strains, which her immune defences could have cleared quickly, so she was discharged fairly quickly.
Third, on Aug 15, the US authorities sent out an urgent report to physicians that two intensive care patients in Washington state who had been infected last month and treated aggressively with Tamiflu were found to have bugs with H274Y.
These four cases suggest that H274Y may already be circulating in the US. It is possible we are seeing relatively few of these isolates for a technical reason: All published genomes are consensus sequences of DNA. That is, the base that is considered to occupy a specific position on the genome is the one that occurs most frequently. But it needs do so 100 per cent of the time.
If a base occurs in only 10 per cent of viral particles, it isn’t likely to show up in the published sequence. It is only when a base occurs in, say, half the cases that it might appear in the consensus sequence.
If H274Y were found in, say, 10 per cent of viral particles, it won’t appear in the consensus sequence of samples taken from a patient prior to Tamiflu being used. Once Tamiflu is employed, the population of sensitive bugs would be drastically reduced. However, those with H274Y would flourish.
Thus, although it was already around prior to Tamiflu being used, the resistant bug would not be detected. After the drug is employed, however, the resistant bugs can grow to greater numbers than the sensitive ones, rendering them detectable.
Of course, if more samples are taken before Tamiflu is used, H274Y might be detected more often. Such comprehensive surveillance, however, would consume too much resources.
History suggests it was limited testing that enabled Tamiflu-resistance in seasonal Influenza A (H1N1) to creep up on the world unawares. The first instance of that was detected in Norway in spring last year.
By the 2008/2009 season, however, it was found in 98 per cent of bugs worldwide. Yet a re-testing of old samples showed that H274Y was already widespread by the autumn of 2007. This means it was circulating in the community before it was first detected in Norway last year.
Is history repeating itself? If so, Singapore should be stocking up on Relenza, the other antiviral that still works. — Straits Times