United States H1N1 With Tamflu and Adamantane Resistance
Recombinomics Commentary 19:03
January 16, 2009
The CDC flu report for week 1 describes antiviral resistance results on 15 additional H1N1 isolates. As expected, all 15 have H274Y. However, one of those 15 also has adamantine resistance. H1N1 with resistance to both antivirals had been reported in isolates from Hong Kong last season. However, these were clade 2C (Hong Kong/2652) isolates and all 2C isolates were adamantane resistant (S31N), and the acquisition of H274Y was not unexpected.
However, this season results from Japan and Korea indicate clade 2C isolates are rare, since almost all isolates have H274Y and are adamantine sensitive. This pattern had also been observed in the United States. Last season clade 2C was frequently detected in western states, and were most common in Hawaii. Sequences from Hawaii were clade 2B and were from isolates that were adamantane sensitive, while clade 2C isoaltes were adamnatane resistant but oseltamivir sensitive.
The finding of adamantine resistance in an H1N1 that was oseltamivir resistance could represent a clade 2C isolate similar to those reported in Hong Kong. Alternatively, this isolate could be clade 2B which has developed adamantine resistance due to use of rimantadine in areas which had high levels of H1N1, which is the current situation in almost all areas of the United States.
The H1N1 is characterized as Brisbane/59-like, but those determinations are based on cross reactivity with ferret antisera, which varies from batch to batch. A classification based on phylogenetic analysis would be more precise. Last season all H1N1 in the US was Brisbane (clade 2B ) or Hong Kong (clade 2C), yet all were called Solomon Island-like (clade 2A) based on cross reactivities with ferret antisera directed against H1N1 grown in chicken eggs, which produced broad cross reactivities among all three clade 2 groupings, but antisera generated with H1N1 in mammalian cells produced activities which readily distinguished clade 2B from clade 2C or clade 2A.
Thus, it remains unclear if the H1N1 that is sensitive to oseltamivir and adamantanes is clade 2C, as had been seen previously in Hong Kong, or was clade 2B that had developed adamantine resistance, which had not been reported previously.
More information on the isolate with resistance to oseltamivir and adamantanes would be useful.
.
__________________
"The next major advancement in the health of American people will be determined by what the individual is willing to do for himself"-- John Knowles, Former President of the Rockefeller Foundation
Overall influenza activity in Canada remains low During week 01, influenza activity in Canada remained low overall with the majority of the influenza surveillance regions still reporting no activity. Nineteen regions (in NT, BC, AB, ON, QC & NB) reported sporadic influenza activity and localized activity was reported in 3 regions (in SK and in ON) (see map). The proportion of tests that were positive for influenza continued to increase steadily with a percentage positive of 3.6% (118/3,306) this week (see table). The majority of influenza virus detections to date this season were influenza A viruses (54% or 223/414); however influenza B detections have slowly increased over the last several weeks. In week 01, the ILI consultation rate declined slightly from the previous week to 18 ILI consultations per 1,000 patient visits (see ILI graph), and it remains below the expected range for this week. The sentinel response rate was 64%. In week 01, 2 new influenza outbreaks were reported (1 LTCF outbreak in ON and 1 other outbreak in SK). Other Respiratory Viruses: RSV detections for Canada as a whole in week 01 remain high; however the percent positive for this week is slightly less than observed in the previous week. Detections for adenoviruses and parainfluenza viruses remain at fairly low levels (see graph). Antigenic Characterization:
Since 1 September 2008, the NML has antigenically characterized 69 influenza viruses: 16 influenza A/Brisbane/59/2007(H1N1)-like (from BC, AB, ON & NS), 2 influenza A/Brisbane/10/2007(H3N2)-like (from BC & ON), 4 influenza B/Florida/4/2006-like (from AB & ON) and 47 B/Malaysia/2506/2004-like (from QC, ON & AB). A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2) and B/Florida/4/2006 are the influenza A and influenza B components recommended for the 2008-09 influenza vaccine. B/Malaysia/2506/2004 was the influenza B component for the 2007-2008 season vaccine (see pie chart). Antiviral Resistance: Results from the NML:
Since the start of the season, the NML has tested 23 influenza A isolates (16 H1N1 and 7 H3N2) for amantadine resistance. All of the H1N1 isolates were susceptible; however all of the H3N2 isolates were resistant to amantadine (resistance = 100% or 7/7). The resistant isolates were from ON, AB and BC.
The NML has also tested 51 influenza isolates (15 A/H1N1, 2 A/H3N2 & 34 B) for oseltamivir (Tamiflu) resistance. All of the A/H3N2 and B isolates were sensitive; however all of the A/H1N1 isolates were resistant to oseltamivir due to the H274Y mutation (resistance = 100% or 15/15). The resistant isolates were from NS, ON, AB and BC.
All 47 influenza isolates (11 A/H1N1, 2 A/H3N2 & 34 B) tested for zanamivir resistance to date were sensitive to zanamivir. Oseltamivir resistance findings from Provincial laboratories:
To date this season, 37 influenza isolates in BC have been sub-typed as A/H1 and were assessed genotypically for oseltamivir resistance using an SNP assay. Twenty-eight isolates tested positive for the H274Y mutation (resistance = 100% or 28/28), with the other 9 specimens still pending confirmatory testing. Influenza-associated Paediatric Hospitalizations:
No laboratory-confirmed influenza-associated paediatric hospitalizations have been reported through the Immunization Monitoring Program Active (IMPACT) network for the 2008-09 season. International:
CDC: During week 53, influenza activity in the United States remained at approximately the same level as in the previous week. More states reported regional and local influenza activity compared to previous weeks, however the majority still reported either no activity or sporadic activity. Of the 2,488 specimens tested this week for influenza viruses, 79 (3.2%) were positive. Since 1 October 2008, the CDC has antigenically characterized 110 influenza viruses: 68 influenza A(H1) (all A/Brisbane/59/2007-like), 13 A(H3) (all A/Brisbane/10/2007-like) and 29 influenza B (9 were B/Florida/04/2006-like belonging to the B/Yamagata lineage and the other 20 belonged to the B/Victoria lineage). Since 1 October, 2008, 142 influenza viruses (88 A(H1N1), 14 A (H3N2), and 40 B) have been tested for resistance to neuraminidase inhibitors. Of the A(H1N1) viruses tested, 98% (86/88) were resistant to oseltamivir however all were sensitive to zanamivir. All of the A(H3N2) and B viruses tested were sensitive to both oseltamivir and zanamivir. The CDC tested 102 influenza A viruses (88 H1, 14 H3) for amantadine resistance: all of the H1N1 viruses were sensitive to amantadine however all the H3N2 viruses were resistant.
EISS: Influenza activity continued to spread across Europe with most countries now reporting medium intensity. Most of the influenza virus detections so far have been for influenza A viruses of which the majority were A(H3). Of the 93 A(H3N2) isolates that were also tested for adamantanes susceptibility, 88 (95%) were resistant. Of the 52 A(H1N1) virus isolates tested for resistance against neuraminidase inhibitors, 51 were resistant to oseltamivir (resistance=98%), but all were sensitive to zanamivir.
Human Avian Influenza: Since 10 January 2009, the WHO has reported 1 new case of human H5N1 avian influenza infection from Egypt. The case was a 21-month-old female from Kerdasa District who developed symptoms on 9 January 2009, was hospitalized on 10 January and is currently in a stable condition. Investigations into the source of her infection indicate a recent history of contact with sick and dead poultry.
Total number of influenza tests performed and number of positive tests by province/territory of testing laboratory, Canada, 2008-2009
Province of
reporting
laboratories
Report Period:
January 4, 2009 to January 10, 2009
Season to Date:
August 24, 2008 to January 10, 2009
Total #
Influenza
Tests
# of Positive Tests
Total #
Influenza
Tests
# of Positive Tests
Influenza A
Influenza B
Total
Influenza A
Influenza B
Total
NL
22
0
0
0
205
0
0
0
PE
7
0
0
0
63
0
0
0
NS
27
0
0
0
285
1
0
1
NB
30
1
0
1
226
1
0
1
QC
874
13
1
14
7955
65
5
70
ON
1138
21
45
66
10109
44
118
162
MB
99
0
1
1
939
0
1
1
SK
186
3
0
3
1588
3
0
3
AB
833
16
3
19
8907
58
64
122
BC
90
12
2
14
744
51
3
54
Canada
3306
66
52
118
31021
223
191
414
Specimens from NT, YT, and NU are sent to reference laboratories in other provinces. Note: Cumulative data includes updates to previous weeks; due to reporting delays, the sum of weekly report totals do not add up to cumulative totals. Abbreviations: Newfoundland/Labrador (NL), Prince Edward Island (PE), New Brunswick (NB), Nova Scotia (NS), Quebec (QC), Ontario (ON), Manitoba (MB), Saskatchewan (SK), Alberta (AB), British Columbia (BC), Yukon (YT), Northwest Territories (NT), Nunavut (NU) Respiratory virus laboratory detections in Canada, by geographic regions, are available weekly on the following website:
<http://www.phac-aspc.gc.ca/bid-bmi/dsd-dsm/rvdi-divr/index-eng.php>
Number of influenza surveillance regions† reporting widespread or localized influenza activity, Canada, by report week, 2008-2009 (N=54)
† sub-regions within the province or territory as defined by the provincial/territorial epidemiologist. Graph may change as late returns come in.
Influenza Activity Level by Provincial and Territorial
Influenza Surveillance Regions, Canada,
January 4, 2009 to January 10, 2009 (Week 01)
Influenza tests reported and percentage of tests positive, Canada, by report week, 2008-2009
Percent positive influenza tests, compared to other respiratory viruses, Canada, by reporting week, 2008-2009
Influenza strain characterization, Canada, cumulative, 2008-2009 influenza season by the Respiratory Viruses Section at the National Microbiology Laboratory
[N=69]
{Strain characterization, number identified, per cent of total number} NACI recommends that the trivalent vaccine for the 2008-2009 season in Canada contain
A/Brisbane/59/2007 (H1N1)-like virus; an A/Brisbane/10/2007 (H3N2)-like virus; and a B/Florida/4/2006-like virus.
Influenza-like illness (ILI) consultation rates, Canada, by report week,
2008-2009 compared to 1996/97 through to 2007/08 seasons
Note: No data available for mean rate in previous years for weeks 19 to 39 (1996-1997 through 2002-2003 seasons).
Number of New Outbreaks in Long Term Care Facilities, Canada, by Report Week, 2008-2009
Testing in Canada
indicated that 26% of last season’s A/H1N1
isolates were resistant to oseltamivir. To date
(January 15), BCCDC has assessed 37 A/H1N1
isolates for oseltamivir resistance; 28 show genotypic evidence of oseltamivir resistance,
and the other 9 are indeterminate and
undergoing further assessment through
sequencing of the neuraminidase gene. None of
these specimens was associated with an
outbreak. Thus, all A/H1N1 specimens for which oseltamivir sensitivity could be determined have so far been found resistant to date in BC during
the 2008-09 season.
Drug susceptibility testing at the NML as of Jan
14 showed that all (n=15) H1N1 isolates tested
Pennsylvania Influenza Cases confirmed by the Bureau of Laboratories
(as of 01/20/2009)
District (#)
County
Subtype
Oseltamivir Resistance (Yes or No)
NW (4)
Erie
1, A(H1N1)
Yes
Warren
2, A(H3N2)
Results pending
Warren
1 A(not typed)
Results pending
NE (15)
Lehigh
1, A(H1N1)
Yes
Luzerne
1, Influenza B
Results pending
Bethlehem
4, A(H3N2)
Results pending
Bethlehem
1, A(H1N1)
Results pending
Allentown
2, A(H3N2)
Results pending
Northampton
5, A(H1N1)
Results pending
Northampton
1, A(H3N2)
Results pending
NC (6)
Centre
2, A(H1N1)
Results pending
Centre
2, Influenza B
Results pending
Montour
2, A(H1N1)
Results pending
SE (5)
Chester
1, A (H3N2)
Results pending
Berks
3, A(H1N1)
Results pending
Bucks
1, A(H1N1)
Yes
SC (1)
Blair
1, A(H1N1)
Results pending
SW (2)
Butler
1, A(H1N1)
Results pending
Allegheny
1, A(H1N1)
Results pending
Results in the table above are based on tests done on a few specimens that are submitted to the State lab by physicians, hospitals and nursing homes. The State lab sends subtyped flu isolates to CDC for further testing.
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
Epidemiological Surveillance for Influenza-like Illness performed by CIRI (Centro Interuniversitario per lo Studio dell'Influenza) and the network of sentinel family doctors.
Global incidence is now above the peak value for 2007/2008 season. Highest incidence is among population in 0-4 class age (11.25 per 1,000 inhabitants; 1125 per 100,000).
-
------
__________________
GIMI69 (IRONOREHOPPER)
--
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
[Original PDF Document is available in Italian at Ministry of Health website; please follow this LINK. EDITED. Manual Translation from Italian by IOH]
From this update, an overview of influenza viruses surveillance for antivirals resistance will be added.
-- ITALY
During latest surveillance week 142 clinical samples have been collected. Among them,40 samples have been found positive for influenza viruses, of these27 were A/H3 and 5 A/H1.
All of the five A/H1 influenza viruses were isolated by Parma's University and they are the first H1 isolates since the start of this season.
Table below summarizes virological surveillance findings since the start of the season (sett. 46-08) to date (sett. 3-09).
Virological surveillance across Europe indicate an increasing circulation of influenza viruses. 2150 samples have been collected. Among them 1275, (59.3%), were influenza virus positive; of these 1229 were type A (360 H3, 11 H1 and the remaining 858 not yet subtyped). Only 46 isolates were type B. Influenza viruses type A are at the moment the predominant strains.
Influenza viruses circulation is increasing. 3066 samples have been collected, among them 221, (7.2%), were influenza positive. Of these, 29 were type A/H1, 12 type A/H3, and the remaining 133 were type A but further subtyping is ongoing. 47 were type B.
None of the influenza viruses type A/H3N2 isolated to date in Italy has been demonstrated to be resistant to oseltamivir.
-- Situation in Europe:
Preliminary results for detection of resistant viruses demonstrate that of 93 influenza viruses type A/H3N2 analyzed to date, all of them were susceptible to both oseltamivir and zanamivir. Viral samples came from Italy, Norway, Spain and Sweden.
However, 98% of the influenza type A/H1N1 viruses analyzed to date were resistant to oseltamivir but retained susceptibility to zanamivir. See (http://ecdc.europa.eu). Table 1: results from Germany, Norway, United Kingdom, Spain and Sweden.
-- Situation in Italy:
None of the influenza type A/H3N2 viruses isolated in Italy to date was oseltamivir-zanamivir resistant.
Table 1 . Virus A/H1N1 resistant to Oseltamivir in Europe
Country - virus A/H1N1 isolated - virus A/H1N1 resistant to Oseltamivir - % virus resistant
Antivirals resistance assays performed by NIC - ISS.
-
-----
__________________
GIMI69 (IRONOREHOPPER)
--
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
Summary of UK* surveillance of influenza and other seasonal respiratory illness
21 January 2009 (Week 04
)
Summary
Clinical indices of acute respiratory illness
(England, Wales, Scotland and Northern Ireland)
The overall influenza-like illness incidence rate**
decreased from 44.3 per 100,000 in week 02/09 to 31.6
per 100,000 in week 03/09. This rate is still above the
baseline threshold of 30 per 100,000. The rates for all
three regions decreased correspondingly. The rate in
the northern region was lowest at 22.2 per 100,000, in
the central region it was 26.9 per 100,000 and in the
south the rate was 38.2 per 100,000. The rates have
*
Incorporating data from the Royal College of General Practitioners (RCGP) (England and Wales), The National Public Health
Service for Wales (NPHS), Health Protection Scotland (HPS), Communicable Disease Surveillance Centre Northern Ireland
(CDSC Northern Ireland), the Office for National Statistics (ONS) (England and Wales), Medical Officers of Schools Association
(MOSA) (England), NHS Direct (England and Wales) and Q Surveillance (England, Northern Ireland, Scotland and Wales).
Figure 1
: RCGP consultation rate for influenza – like illness, 2008/09 and recent years, England and Wales
Influenza activity is decreasing across the UK.
In week 03/09 GP consultation rates remained above the threshold levels but have decreased in England and
Scotland. In Wales the rate has increased slightly but remains below baseline. In Northern Ireland the consultation
rate has decreased but thresholds have not yet been set. The proportion of cold/flu calls to NHS direct in England and
Wales has decreased, and the proportion of fever calls in those aged 5-14 has increased slightly but remains below
baseline.
In week 03/09 48 specimens tested positive for influenza virus (six influenza A (H1), 39 influenza A (H3) and three
influenza B) at the Centre for Infections’ Respiratory Virus Unit (RVU). Other NHS and HPA laboratories in England
and Wales reported 95 influenza A, and three influenza B positive specimens in week 03/09. Seventy-six Scottish and
13 Northern Irish influenza positive specimens were reported in week 03/09. Six outbreaks of respiratory illness were
reported recently in care homes, a hospital and a school in different parts of England. The proportion of people over
65 years who have received this season’s influenza vaccine was 73.9% in week 03/09, and 46.5% in those aged
under 65 years in risk groups. Characterisation of 375 influenza viruses since week 40/08 by RVU have shown that
the majority of circulating strains are well-matched to the current influenza vaccine.
Most European countries reported influenza activity of medium intensity with only a limited number of countries,
mostly in east and north east Europe, reporting low influenza activity in week 02/09.
England and Wales
Royal College of General Practitioners
(
http://www.rcgp.org.uk/bru/index.asp)
Covered in this report:
Data, except that from ONS, MOSA and non-UK sources: 12/01/09 - 18/01/09 (Week 03, 2009 )
Data from ONS, MOSA and non-UK sources: 05/12/08 - 11/01/09 (Week 02, 2009)
** RCGP incidence rates in this report only refer to first or new episodes of infection diagnosed by a GP.
Since week 40/08 all of the influenza A (H3) isolates that have been tested for drug sensitivity have been found to be
sensitive to oseltamivir and zanamivir, but resistant to amantadine. Forty influenza A (H1) specimens have been
tested for anti-viral drug resistance, 39 of these were resistant to oseltamivir and all were sensitive to zanamivir and
amantadine.Two influenza B specimens have been tested so far and both were sensitive to oseltamivir and zanamivir.
Antiviral drug susceptibility testing
decreased in most age groups with the highest now in
the 65-74 year group at 45.2 per 100,000, which is a
slight increase from the rate of 42.3 per 100,000 in the
previous week , but is not as high as the peak in this age
group of 70.2 per 100,000 in week 01/09. (Figure 2).
The rate for acute bronchitis also decreased from 182.7
per 100,000 in week 02/09 to 129.8 per 100,000 in week
03/09 . The highest rate is still in the over 75 year group
at 416.7 per 100,000 in week 02/09, though this has
decreased from 542.1 per 100,000 in week 02/09.
E n g l a n d ( R C G P )
S c o t l a n d ( H P S )
W a l e s ( N P H S )
N o r t h e r n I r e l a n d ( C D S C N I )
Figure 3
: GP Consultation rates for influenza/influenza-like illness in the U.K
QSurveillance
HPA and Nottingham University Division of Primary
Care.
(
http://www.qresearch.org)
Northern Ireland
CDSC Northern Ireland
(
http://www.cdscni.org.uk/)
The combined rate for influenza and influenza-like illness
decreased from 157.3 per 100,000 in week 02/09 to 112.6
per 100,000 in week 03/09 (Figure 3). No threshold has
been set for Northern Ireland.
This primary care surveillance system uses
QSurveillance, a database of general practice derived
data. During week 03/09, over 3200 practices reported
from England, Wales, Scotland and Northern Ireland
covering a population of over 21 million. The rate of
influenza-like illness decreased from 30.3 per 100,000
in week 02/09 to 18.7 per 100,000 in week 03/09. The
highest rate is in the 45-64 year age group (25.1 per
100,000). The rates were highest in Northern Ireland,
the south west of England and London.
NHS Direct total call activity
England and Wales
(
http://www.nhsdirect.nhs.uk/)
The proportions of cold/flu calls decreased from 1.2 % in
week 02/09 to 0.8% in week 03/09, which is below the
threshold of 1.2%. The proportion of fever calls in 5-14
year olds increased from 4.9% in week 02/09 to 6.6% in
week 03/09 but remains below the threshold of 9%.
Wales
National Public Health Service
(
http://www.wales.nhs.uk/sites/home.cfm?OrgID=368)
GP consultation rates for influenza increased slightly from
11.6 per 100,000 in week 02/09 to 12.8 per 100,000 in
week 03/09. Both figures are below the baseline
threshold of 25 consultations per 100,000 (Figure 3).
Figure 2
: RCGP Episode incidence rates for influenza-like illness (ILI) by age group, England and Wales.
W e e k
Rate per 100 000 population
0 - 1
1 - 4
5 - 1 4
1 5 - 4 4
4 5 - 6 4
6 5 - 7 4
> 7 5
Medical Officers of Schools Association (MOSA)
Scotland
Health Protection Scotland
(
http://www.hps.scot.nhs.uk/)
GP consultation rates for influenza decreased from 92.0
per 100,000 in week 02/09 to 68.0 per 100,000 in week
03/09 (Figure 3). This still exceeds the Scottish baseline
threshold of 50 consultations per 100,000.
In week 02/09 25 schools reported data. There were 13
new episodes of upper respiratory tract infection giving
a rate of 1.94 per 1000, which is low compared to the
peak this season in week 50/08 with 260 episodes giving
a rate of 118.4 per 1000. In week 02/09 there were five
new episodes of influenza or ILI which gives a rate of
0.75 per 1000. This is also low compared the the peak
of 23 episodes and a rate of 10.4 per 1000 in week 49/
08
3
Respiratory Virus Unit (RVU) Influenza Reference
Laboratory, CfI
In week 03/09 48 specimens tested positive for influenza;
six A (H1), 39 A (H3) and 3 B (table 1). Since week 40/08
347 viruses have been characterised: 34 A (H1) Brisbane/
59/2007 (H1N1)-like, 321 A (H3) A/Brisbane/10/2007
(H3N2)-like, four B/Florida/4/2006-like which are all vaccine
strains, and 16 B/Malaysia/2506/2004-like.
19.1% of
specimens from the RCGP surveillance scheme were
positive for influenza in week 03/09 (figure 4), this is a
decrease from 26.7% positive in week 02/09. Since
week 40/08, all 101 A (H3) isolates that have been tested
have been found to be resistant to amantadine, of these
74 have been tested and found to be sensitive to
oseltamivir and zanamivir. Forty influenza A (H1) specimens
have been tested for anti-viral resistance since week 40/
08, 39 of these were resistant to oseltamivir and all were
sensitive to zanamivir and amantadine. Two influenza B
specimens have been tested so far and were sensitive to
oseltamivir and zanamivir.
* RSV detection is by PCR only
Other NHS and HPA laboratories (England and
Wales)
The number of specimens positive for influenza A has
decreased from 168 in week 02/09 to 95 in week 03/
09, the number of influenza B positives has stayed fairly
constant at three in week 03/09 and the number of RSV
positives decreased (from 264 to 219) in the same
time period (Table 2).
Please note that these data are provisional.
Laboratory indices of acute respiratory illness
*
Detections of RSV by isolation are not included.
Table 1 “Detections” (PCR and isolation) of influenza and
RSV made by RVU (CfI) Reference Laboratory.
Samples from community and hospital sources,
by week of report.
63 1055 48 43
Influenza Detections by
PCR and Isolation
A (H1) A (H3) B RSV*
Cumulative to date
Northern England
Central England
Southern England
Wales
Scotland
Northern Ireland
Cumulative Total
Influenza type ( subtype)
Week 02/09
Week 03/09
(week 40/08 – 02/09)
356 336 3922
Table 2 ‘‘Detections” (isolation, PCR, direct
immunofluorescence and paired sera tests) of
influenza and RSV reported to CfI by NHS and
HPA microbiology laboratories. Data for England
and Wales by RCGP region, by week of report
Week 02/09
Week 03/09
Cumulative to Date
(week 40/08 - 03/09)
Northern England
Central England
Southern England
Wales
Cumulative Total
Detection (isolates, DIF and PCR)
Influenza A Influenza B RSV*
168 4 264
95 3 219
267 17 1355
328 8 623
384 4 1894
46 0 279
1025 29 4151
4 61 5 3
6 39 3 3
Figure 4 : Proportion of RCGP specimens positive for influenza detected (PCR and Isolation) by RVU,CfI, by week of
specimen
% I n f l u e n z a B
% I n f l u e n z a A ( H 1 )
% I n f l u e n z a A ( H 3 )
Four (20%) of 20 samples submitted in weeks 01 and
02/09 from this parallel GP sentinel scheme were
positive for influenza A. Between weeks 40/08 and 02/
08, 645 specimens have been submitted and 213
(33%) have been positive for influenza; 200 influenza A
and 13 influenza B.
HPA CfI Virological Surveillance of Influenza
(England)
Please note that these data are provisional.
4
Avian Influenza
The WHO continues to monitor and report on new cases
of human infection with A(H5N1) avian influenza when
they occur. On 19 January WHO reported three cases of
influenza A (H5N1) in different provinces of China, one
has died. According to WHO, the total number of
confirmed human infections worldwide with H5N1, since
December 2003, is 397 of which 249 (63%) have died.
Five sentinel samples were tested in week 03/09 of
which three (21%) were positive for influenza (two A
and one B). Of the 62 non-sentinel samples tested,
10 (16%) were positive for influenza (nine A and one
B) and 12 for RSV.
Flu Vaccination Campaign 2008/09 (England)
Data on influenza vaccination uptake is taken weekly from
a sample of GPs in England.
Steady increasing trends have been seen since since
the start of the campaign in September 2008.
In week 03/09 the proportion vaccinated in the over 65
year age group reached 73.9% and in the under 65 years
at risk group, the proportion vaccinated was 46.5%.
Outbreak Reports:
There have been six outbreaks of respiratory disease
reported recently, four of which have been confirmed as
influenza A. Four are from care homes in England; one
in the east of the country, two in the south east, one in the
west Midlands, which may be linked to an outbreak in a
hospital in the same area. One outbreak has been
reported from a school in Yorkshire and the Humber.
CfI welcomes reports of respiratory illness outbreaks.
A reporting form can be found at:
In week 02/09 an estimated 15,233 deaths were
registered, with 3334 (21.9%) giving respiratory disease
as an underlying cause. In week 01/09 an estimated
3035 (22.4%) of 13,560 registered deaths were due to
respiratory illness. In the five week period from week
50/08 to week 02/09 HPA estimates that there have been
approximately 6300 all-cause excess deaths compared
the expected number at this time of year. It should be
noted that this excess mortality is due to all causes and
cannot be specifically attributed to influenza. The
estimated weekly all-cause registered deaths are shown
in figure 5.
Other Reports (UK)
During week 03/09, 12 (29%) out of 41 sentinel
samples were positive for influenza; nine A (three A
(H3)) and three B. Two sentinel samples were positive
for RSV and two were positive for other viruses. One
hundred and five routine samples were also tested; 64
(77%) were positive for influenza; 54 A and ten B; two of
the influenza A positive samples were also positive for
RSV and 41 further were positive for RSV alone.
Figure 5 : Weekly all cause registered deaths in England and Wales
In week 02/09 two (13%) of 15 sentinel samples were
positive for influenza A. To date this season 15 of 77
(19%) sentinel samples and 49 non-sentinel samples
have been positive for influenza A.
* Provisional data, above threshold
5
Data for this report were collated by the Influenza/
Respiratory Virus Team:
Estelle McLean, Joy Field, Richard Pebody and John
Watson
Respiratory and Systemic Infections Department
HPA Centre for Infections, 61 Colindale Avenue
London NW9 5EQ, United Kingdom
Tel: (0)20 8327 7768; Fax: (0)20 8200 7868
E-mail:
respcdsc@hpa.org.uk
Maria Zambon, Joanna Ellis, Angie Lackenby, Alison
Bermingham and Praveen Sebastianpillai
Respiratory Virus Unit, Virus Reference Department
HPA Centre for Infections, 61 Colindale Avenue
London NW9 5HT, United Kingdom
Tel: (0)20 8327 6239; Fax: (0)20 8205 8195
E-mail:
ernvl@hpa.org.uk
If you wish to be included on our email notification list
please send your address to:
respcdsc@hpa.org.uk
Acknowledgements
Canada
Public Health Agency of Canada
(
http://www.phac-aspc.gc.ca/fluwatch/index.html)
During week 02/09, influenza activity remained low with
the majority of the influenza surveillance regions reporting
no activity, 19 regions reporting sporadic activity and three
reporting localised influenza activity. Overall, there was a
decrease in the consultation rates. One hundred and
eighteen of 3306 (3.6%) specimens tested positive for
influenza and two influenza outbreaks were reported in
week 01/09.
Since 1 September 2008, 69 influenza viruses have been
characterised: 16 influenza A/Brisbane/59/2007(H1N1)-
like, two A/Brisbane/10/2007 (H3N2)-like, four influenza
B/Florida/4/2006-like and 47 B/Malaysia/2506/2004-like,
the latter was a component of the 2007/08 vaccine.
Forty-three influenza A (H1N1) isolates have been tested
and found to be resistant to oseltamivir.
Ireland
Health Protection Surveillance Centre (HPSC)
(
http://www.hpsc.ie/)
The Irish ILI consultation rate decreased from 120.5
(updated rate) per 100,00 in week 02/09 to 103.1 per
100,000 population in week 03/09. Both rates are well
above the Irish baseline threshold of 17.8 per 100,000
population.
In week 03/09 14 (50%) of 34 sentinel samples were
positive for influenza (seven A (H3), five A untyped and
two B) and three (2.5%) of 122 non-sentinel samples
were positive for influenza A and ten for RSV.
Other country reports can be obtained from the World
Health Organisation:
Most European countries are now experiencing influenza
activity of medium intensity. Only a limited number of
countries, mostly in east and north east Europe are still
reporting low influenza activity. In week 02/09,
influenza
activity was reported as high in Switzerland and Ireland,
medium intensity in 17 countries and low in 10
countries. Geographical spread was reported as
widespread in 14 countries; regional in three countries;
local in two countries; sporadic in six countries; and
no activity was reported in four.
Out of the total 1448 respiratory specimens collected by
sentinel physicians during week 02/09, 573 (39.6%)
specimens tested positive for influenza, 274 type A (not
subtyped), 262 A (H3), seven A (H1) and 30 type B. In
addition, 702 non-sentinel specimens tested positive
including 584 influenza A (not subtyped), 98 A (H3), four
A (H1), and 16 type B.
Since week 40/08, 374 viruses have been characterised;
360 of these seem to be a good match to the strains
recommended for the 2008-09 vaccine, the remaining
14 were B/Malaysia/2506/2004-like.
Influenza activity outside the UK
United States of America
Centers for Disease Control and Prevention (CDC)
(
http://www.cdc.gov/flu/weekly/)
During week 02/09, influenza levels remained low but
increased from the previous week. One state (Virginia)
reported widespread activity, five states reported regional
activity, 10 states reported local influenza activity, the
District of Columbia, Puerto Rico and 33 states reported
sporadic influenza activity, and one state reported no
activity.
In week 01/09 WHO and NREVSS laboratories reported
3394 specimens tested for influenza viruses, 242 (7.1%)
of which were positive: 47 influenza A (H1), 11 A (H3), 156
A (not subtyped) and 28 influenza B.
Since week 40/08 158 influenza viruses have been
characterised; 93 A/Brisbane/59/2007 (H1N1)-like, 13 A/
Brisbane/10/2007 (H3N2)-like, 17 B/Florida/04/2006-like,
which are the components recommended for the 2008-
09 vaccine, and 35 from the B/Victoria lineage. Of the 103
influenza A (H1) viruses tested this season, 101 have
been found to be resistant to oseltamivir, but all are
The map presents the intensity of influenza activity and the geographical spread as assessed by each of the networks in EISS.
Clicking on the map will, if available, take you through to the national web site. If 'regional' activity is reported, a pop-up text box will appear which describes the activity in greater detail.
Clicking on England and France will provide you with regional data.
A = Dominant virus A H1N1 = Dominant virus A(H1N1) H3N2 = Dominant virus A(H3N2) H1N2 = Dominant virus A(H1N2) B = Dominant virus B A & B = Dominant virus A & B
Low = no influenza activity or influenza at baseline levels Medium = usual levels of influenza activity High = higher than usual levels of influenza activity Very high = particularly severe levels of influenza activity
No activity = no evidence of influenza virus activity (clinical activity remains at baseline levels) Sporadic = isolated cases of laboratory confirmed influenza infection Local outbreak = increased influenza activity in local areas (e.g. a city) within a region,
or outbreaks in two or more institutions (e.g. schools) within a region. Laboratory confirmed. Regional activity = influenza activity above baseline levels in one or more regions with
a population comprising less than 50% of the country's total population. Laboratory confirmed. Widespread = influenza activity above baseline levels in one or more regions with a population
comprising 50% or more of the country's population. Laboratory confirmed.
Finland : Where available, the epidemiological data are provided by a health-care district in
South-Western Finland (the health-care district serves 54,000 inhabitants i.e. approximately one
percent of the Finnish population).
Network comments (where available)
Italy
During this last week, among the 40 samples resulted positive for influenza A, the first isolates belonging to H1N1 subtype have been reported in Italy, together with further 27 H3N2 viruses. Serbia
Influenza B/Malaysia/2506/2004-like virus strains were confirmed by Real-time PCR and isolation in MDCK cells in two patients (12 years and 23 years old). Influenza A(H3) was confirmed by Real-time PCR in the samples of a 24 year-old patient Sweden
We had a medium level of inluenza actvity among ILI cases BUT a continue high level of non-sentinel laboratory diagnoses. Switzerland
Influenza activity continued to increase last week. Influenza A are mainly detected. B remained reall sporadic. Influenza A are related to influenza A/Brisbane/10/07 (H3N2) vaccine strain.
Intensity: Low = no influenza activity or influenza activity at baseline level; Medium= usual levels of influenza activity; High = higher than usual levels of influenza activity; Very high = particularly severe levels of influenza activity. Percentage positive: percentage of sentinel swabs that tested positive for influenza A or B Dominant type: this assessment is based on data from sentinel and non-sentinel sources ARI: acute respiratory infection ILI: influenza-like illness Population: per 100,000 population
The bulletin text was written by an editorial team at the European Centre for Disease Prevention and Control (ECDC) and the Community Network of Reference Laboratories for Human Influenza in Europe (CNRL). Team members are Flaviu Plata, Phillip Zucs and Bruno Ciancio from ECDC, and Adam, Meijer Rod Daniels Alan Hay and Maria Zambon from CNRL. The bulletin text was reviewed by Olav Hungnes (Norwegian Institute of Public Health, Oslo, Norway), and Anne Mazick (Statens Serum Institut, Copenhagen, Denmark) on behalf of the EISS members.
Neither the European Centre for Disease Prevention and Control (ECDC), nor any person acting on his behalf is liable for the use that may be made of the information contained in this bulletin. Maps and commentary used in this Bulletin do not imply any opinions whatsoever of ECDC or its partners on the legal status of the countries and territories shown or concerning their borders.
Medium to high influenza activity in most European countries
Summary: In week 03/2009, influenza activity continued to intensify and spread across Europe with most countries now reporting medium to high intensity. In Portugal and the UK (England) activity has continued to decrease. The majority of the viruses identified were influenza A(H3) that continues to be the predominant circulating virus. All the A(H3N2) viruses tested for antiviral resistance were susceptible to neuraminidase inhibitors. Vaccination of risk groups according to national recommendations remains indicated.
Epidemiological situation - week 03/2009: For the intensity indicator, the national network levels of influenza-like illness (ILI) and/or acute respiratory infection (ARI) were high in Austria, Denmark, Ireland, Luxembourg and Switzerland, medium in 15 countries and the UK (England, Northern Ireland and Scotland), and low in the other seven countries and one part of the UK (Wales) that reported this indicator. Of the 21 countries that reported medium or high influenza activity this week, two (Czech Republic and Romania) did so for the first time during the current season.
For the geographical spread indicator, widespread influenza activity was reported in 15 countries and the UK (Northern Ireland), regional activity in one country and the UK (England), local activity in three countries and sporadic or no activity in the remaining eight countries and the UK (Scotland and Wales). Six of the seven countries (Estonia, Hungary, Latvia, Lithuania, Serbia and Slovakia) where the influenza season has not started yet are located in the eastern and north-eastern part of Europe.
All of these reported increasing intensity during week 03/2009 as compared with the previous week. Consultation rates for ILI in the UK (England) peaked in week 1/2009 and have decreased since then. Definitions for the epidemiological indicators can be found here.
Cumulative epidemiological situation – 2008-2009 season (weeks 40/2008-03/2009): Consultation rates for ILI and/or ARI above baseline levels were first reported in Portugal, Ireland and the UK (England and Northern Ireland) in week 49/2008. Subsequently consultations rates rose above baseline levels in Spain (week 51/2008), France and Italy (week 52/2008), Austria, Denmark, Germany, Sweden, Switzerland and the Netherlands (week 01/2009), Belgium, Bulgaria, Greece, Norway, Poland, Slovenia and the UK (Scotland; week 02/2009) and Czech Republic and Romania (week 3/2009) .
High influenza activity has been reported in Portugal (week 51/2008), Ireland (week 01/2009), Switzerland (week 02/2009), Austria, Denmark and Luxembourg (week 3/2009). Influenza activity is now declining in Portugal (since week 52/2008) and the UK (England; since week 2/2009). Generally, the highest consultation rates have been reported for the 0-4 age group, but Ireland, UK and Norway have reported their highest ILI consultation rates in the 15-64 age group.
Virological situation - week 03/2009: The total number of respiratory specimens collected by sentinel physicians in week 03/2009 was 2287, of which 968 (42.3%) were positive for influenza virus: 932 type A (492 subtype H3, 31 subtype H1 and 409 not subtyped) and 36 type B.
In addition, 742 non-sentinel source specimens (e.g. specimens collected for diagnostic purposes in hospitals) were reported positive for influenza virus: 731 type A (185 subtype H3, six subtype H1 and 540 not subtyped) and 11 type B.
Cumulative virological situation – 2008-2009 season (weeks 40/2008-03/2009): Of 7951 virus detections (sentinel and non-sentinel) since week 40/2008, 7662 were type A (3130 subtype H3, 199 subtype H1 and 4333 not subtyped) and 289 were type B. Based on the antigenic and/or genetic characterisation of 794 influenza viruses, 714 were reported as A/Brisbane/10/2007(H3N2)-like, 47 as A/Brisbane/59/2007(H1N1)-like, 11 as B/Florida/4/2006-like (B/Yamagata/16/88 lineage) and 22 as B/Malaysia/2506/2004-like (B/Victoria/2/87 lineage) .
All influenza A(H3N2) viruses tested were sensitive to oseltamivir and zanamivir, whereas 99% of those tested were resistant to M2 inhibitors.
The few influenza B viruses analysed were sensitive to oseltamivir and zanamivir.
All influenza A(H1N1) viruses analysed were sensitive to zanamivir and M2 inhibitors but 98% were resistant to oseltamivir.
Comment: Influenza activity has continued to intensify in Europe with three additional countries reporting high intensity. The west-to-east spread of influenza has continued with two additional countries in eastern Europe reporting medium influenza intensity.
It is anticipated that influenza activity will spread further in the coming weeks and affect the few remaining eastern countries. In a few western countries recent influenza activity has already peaked and started to decline. The proportion of sentinel specimens which tested positive for influenza this week remained high (42.3%).
So far type A(H3) has been the dominant influenza virus circulating in Europe. A higher number of viruses have now been antigenically and/or genetically characterised. These data indicate that, with the exception of the few B/Victoria lineage viruses, the viruses circulating are similar to the three components (A(H1N1), A(H3N2) and B/Yamagata lineage) included in the current influenza vaccine.
Background: The Weekly Electronic Bulletin presents and comments on influenza activity in the 30 European countries that are members of EISS. Of these countries, 28 reported both clinical and virological data and two reported clinical data only to EISS in week 03/2009. The spread of influenza virus strains and their epidemiological impact in Europe are being monitored by EISS under the aegis of the European Centre for Disease Prevention and Control in Stockholm (Sweden) in collaboration with the WHO Collaborating Centre in London (UK).
As of week 53, twenty samples were found to be positive by viral culture for influenza AH1,
AH3 and influenza B. Rapid and culture results by county are displayed below.
Week 40 to Week 53 Week 51, 52, 53
County
A RapBid * A/ Culture* Rapid* Culture*
B
A
H1
A
H3
A
UNK
B A B A/B A H1 A
H3
A
UNK
B
Atlantic County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bergen County
3 0 0 1 0 0 0 2 0 0 1 0 0 0
Burlington County
9 0 0 0 0 0 0 4 0 0 0 0 0 0
Camden County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Cape May County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Cumberland County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Essex County
18 8 4 1 1 0 0 8 4 1 1 1 0 0
Gloucester County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Hudson County
6 2 0 1 0 0 0 5 1 0 0 0 0 0
Hunterdon County
0 0 8 5 0 0 1 0 0 3 2 0 0 1
Mercer County
1 0 0 0 0 0 0 0 0 0 0 0 0 0
Middlesex County
3 0 0 3 0 0 0 2 0 0 0 0 0 0
Monmouth County
8 0 3 1 1 0 1 0 0 0 1 1 0 0
Morris County
0 0 0 2 0 0 0 0 0 0 2 0 0 0
Ocean County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Passaic County
11 1 0 0 0 0 0 8 1 0 0 0 0 0
Salem County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Somerset County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sussex County
3 2 0 0 0 0 0 0 2 0 0 0 0 0
Union County
1 1 0 1 0 0 1 1 0 0 0 0 0 0
Warren County
0 0 0 0 0 0 0 0 0 0 0 0 0 0
Unknown
0 0 0 0 0 0 0 0 0 0 0 0 0 0
State Total
63 14 15 15 2 0 3 30 8 4 7 2 0 1
*Rapid data is acquired from facilities reporting rapid influenza tests via NREVSS or CDRSS ILI module. Culture
results are obtained from the LIMS system at PHEL, hospital viral culture laboratories via NREVSS or commercial
laboratories reporting in CDRSS. County of residence as provided by the laboratory is used to assign culture results
to a county. If county is residence is not available, the county of the facility reporting is utilized.
2008-2009 Influenza Season Week 1 ending January 17, 2009 (All data are preliminary and may change as more reports are received.) Synopsis:
During week 2 (January 11-17, 2009), influenza activity continued to slowly increase in the United States.
Four hundred nine (11.5%) specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories and reported to CDC/Influenza Division were positive for influenza.
The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold.
Two influenza-associated pediatric deaths were reported.
The proportion of outpatient visits for influenza-like illness (ILI) was below national and region-specific baseline levels.
One state reported widespread influenza activity, six states reported regional activity; 11 states reported local influenza activity; the District of Columbia, Puerto Rico and 30 states reported sporadic influenza activity; and two states reported no influenza activity.
National and Regional Summary of Select Surveillance Components
Region
Data for current week
Data cumulative for the season
Out-patient ILI*
% positive for flu†
Number of jurisdictions reporting regional or widespread activity‡
A (H1)
A (H3)
A Unsub-typed
B
Pediatric Deaths
Nation
Normal
11.5 %
7 of 51
641
104
1292
413
2
New England
Normal
5.2 %
1 of 6
24
5
45
8
0
Mid-Atlantic
Normal
5.3 %
2 of 3
69
11
102
23
0
East North Central
Normal
16.8 %
0 of 5
59
7
24
18
0
West North Central
Normal
4.1 %
0 of 7
31
7
49
20
0
South Atlantic
Normal
5.3 %
2 of 9
54
7
192
113
0
East South Central
Normal
1.3 %
0 of 4
2
0
0
7
0
West South Central
Normal
13.4 %
1 of 4
93
1
629
189
1
Mountain
Normal
12.1 %
1 of 8
49
56
149
11
1
Pacific
Normal
5.7 %
0 of 5
260
10
102
24
0
* Elevated means the % of visits for ILI is at or above the national or region-specific baseline
† National data is for current week; regional data is for the most recent three weeks.
‡ Includes all 50 states and the District of Columbia U.S. Virologic Surveillance:
WHO and NREVSS collaborating laboratories located in all 50 states and Washington D.C. report to CDC the number of respiratory specimens tested for influenza each week. The results of tests performed during the current week and cumulative totals for the season are summarized in the table below.
Week 2
Cumulative for the Season
No. of specimens tested
3544
66499
No. of positive specimens (%)
409 (11.5%)
2,450 (3.7%)
Positive specimens by type/subtype
Influenza A
346 (84.6%)
2,037(83.1%)
A (H1)
44 (12.7%)
641 (31.5%)
A (H3)
4 (1.2%)
104 (5.1%)
A (unsubtyped)
298 (86.1%)
1,292 (63.4%)
Influenza B
63 (15.4%)
413 (16.9%)
The District of Columbia and 45 states from all nine surveillance regions have reported laboratory-confirmed influenza this season.
CDC has antigenically characterized 207 influenza viruses [142 influenza A (H1), 13 influenza A (H3) and 52 influenza B viruses] collected by U.S. laboratories since October 1, 2008.
All 142 influenza A (H1) viruses are related to the influenza A (H1N1) component of the 2008-09 influenza vaccine (A/Brisbane/59/2007). All 13 influenza A (H3N2) viruses are related to the A (H3N2) vaccine component (A/Brisbane/10/2007).
Influenza B viruses currently circulating can be divided into two distinct lineages represented by the B/Yamagata/16/88 and B/Victoria/02/87 viruses. Seventeen influenza B viruses tested belong to the B/Yamagata lineage and are related to the vaccine strain (B/Florida/04/2006). The remaining 35 viruses belong to the B/Victoria lineage and are not related to the vaccine strain. Thirty of the 35 viruses belonging to the B/Victoria lineage were from two states.
Data on antigenic characterization should be interpreted with caution given that antigenic characterization data is based on hemagglutination inhibition (HI) testing using a panel of reference ferret antisera and results may not correlate with clinical protection against circulating viruses provided by influenza vaccination.
Annual influenza vaccination is expected to provide the best protection against those virus strains that are related to the vaccine strains, but limited to no protection may be expected when the vaccine and circulating virus strains are so different as to be from different lineages, as is seen with the two lineages of influenza B viruses. Antiviral Resistance:
Since October 1, 2008, 160 influenza A (H1N1), 30 influenza A (H3N2), and 66 influenza B viruses have been tested for resistance to the neuraminidase inhibitors (oseltamivir and zanamivir). One hundred thirty-three influenza A (H1N1) and 26 influenza A (H3N2) viruses have been tested for resistance to the adamantanes (amantadine and rimantadine). The results of antiviral resistance testing performed on these viruses are summarized in the table below.
Isolates tested (n)
Resistant Viruses,
Number (%)
Isolates tested (n)
Resistant Viruses, Number (%)
Oseltamivir
Zanamivir
Adamantanes
Influenza A (H1N1)
103
101 (98%)
0 (0)
103
1 (1%)
Influenza A (H3N2)
23
0 (0)
0 (0)
23
23 (100%)
Influenza B
61
0 (0)
0 (0)
N/A*
N/A*
*The adamantanes (amantadine and rimantadine) are not effective against influenza B viruses.
Influenza A (H1N1) viruses from 25 states have been tested for antiviral resistance to oseltamivir so far this season. In all 25 states, at least one oseltamivir-resistant influenza A (H1N1) virus has been identified. To date, all influenza A (H3N2) viruses tested are resistant to the adamantanes. Influenza activity in the United States, although increasing, remains relatively low with influenza A(H1N1) viruses predominating overall. However, the level of activity and the predominating virus has varied by region and may vary over the course of the season. This presents challenges for the selection of antiviral medications for the treatment and chemoprophylaxis of influenza and highlights the importance of testing patients for influenza and consulting local surveillance data when evaluating patients with acute respiratory infections during the influenza season. CDC issued interim recommendations for the use of influenza antiviral medications in the setting of oseltamivir resistance among circulating influenza A (H1N1) viruses on December 19, 2008. These interim recommendations are available at http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00271. Pneumonia and Influenza (P&I) Mortality Surveillance
During week 2, 7.5% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage is below the epidemic threshold of 7.8% for week 2.
Two influenza-associated pediatric deaths were reported to CDC during week 2 (Colorado and Texas). These deaths occurred during week 1 (week ending January 10, 2009). Since September 28, 2008, CDC has received a total of two reports of influenza-associated pediatric deaths that occurred during the current season.
Laboratory-confirmed influenza-associated hospitalizations are monitored in two population-based surveillance networks: the Emerging Infections Program (EIP) and the New Vaccine Surveillance Network (NVSN).
No influenza-associated hospitalizations have been reported from the New Vaccine Surveillance Network this season.
During October 1, 2008 – January 17, 2009, preliminary laboratory-confirmed influenza-associated hospitalization rates reported by the EIP for children aged 0-4 years and 5-17 years were 0.6 per 10,000 and 0.02 per 10,000, respectively. For adults aged 18-49 years, 50-64 years, and = 65 years, the rates were 0.05 per 10,000, 0.08 per 10,000, and 0.2 per 10,000, respectively.
During week 2, 1.5% of patient visits reported through the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) were due to influenza-like illness (ILI). This percentage is less than the national baseline of 2.4%. On a regional level, the percentage of visits for ILI ranged from 0.3% to 3.7%. The percentage of visits for ILI reported from all nine surveillance regions was below their respective region-specific baselines.
The increase in the percentage of patient visits for ILI over the previous weeks may have been influenced by a reduction in routine health care visits during the holiday season, as has occurred in previous seasons.
During week 2, the following influenza activity was reported:
Widespread influenza activity was reported by one state (Virginia).
Regional influenza activity was reported by six states (Colorado, New Hampshire, New Jersey, New York, North Carolina, and Texas).
Local influenza activity was reported by 11 states (Arizona, Connecticut, Florida, Hawaii, Illinois, Maryland, Massachusetts, Michigan, Montana, Pennsylvania, and Tennessee).
Sporadic activity was reported in the District of Columbia, Puerto Rico, and 30 states (Alabama, Alaska, Arkansas, California, Delaware, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Missouri, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Oregon, Rhode Island, South Carolina, South Dakota, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming).
No influenza activity was reported by two states (Mississippi and Oklahoma).
--------------------------------------------------------------------------------
A description of surveillance methods is available at: http://www.cdc.gov/flu/weekly/fluactivity.htm
Influenza activity in Canada is increasing; six regions reporting localized activity
During week 02, influenza activity in Canada started to increase with more regions reporting localized (n=6; in ON, AB, BC & NT) and sporadic activity (n=20).The majority of regions still reported no activity (n=28) (see map). The proportion of tests that were positive for influenza continued to increase steadily with a percentage positive of 5.5% (170/3,111) this week (see table). The majority of influenza virus detections to date this season were influenza A viruses (57.4% or 335/584). In week 02, the ILI consultation rate was 16 ILI consultations per 1,000 patient visits (see ILI graph), which is below the expected range for this week. The sentinel response rate was 64%. In week 02, 5 new influenza outbreaks were reported: 3 in LTCFs (in ON, BC & NT), 1 in a hospital and 1 in a school (both from BC). Antigenic Characterization:
Since 1 September 2008, the NML has antigenically characterized 69 influenza viruses: 16 influenza A/Brisbane/59/2007(H1N1)-like (from BC, AB, ON & NS), 2 influenza A/Brisbane/10/2007(H3N2)-like (from BC & ON), 4 influenza B/Florida/4/2006-like (from AB & ON) and 47 B/Malaysia/2506/2004-like (from QC, ON & AB). A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2) and B/Florida/4/2006 are the influenza A and influenza B components recommended for the 2008-09 influenza vaccine. B/Malaysia/2506/2004 was the influenza B component for the 2007-2008 season vaccine (see pie chart). Antiviral Resistance: Results from the NML:
Since the start of the season, the NML has tested 23 influenza A isolates (16 H1N1 and 7 H3N2) for amantadine resistance. All of the H1N1 isolates were susceptible; however all of the H3N2 isolates were resistant to amantadine (resistance = 100% or 7/7). The resistant isolates were from ON, AB and BC.
The NML has also tested 51 influenza isolates (15 A/H1N1, 2 A/H3N2 & 34 B) for oseltamivir (Tamiflu) resistance. All of the A/H3N2 and B isolates were sensitive; however all of the A/H1N1 isolates were resistant to oseltamivir due to the H274Y mutation (resistance = 100% or 15/15). The resistant isolates were from NS, ON, AB and BC.
All 47 influenza isolates (11 A/H1N1, 2 A/H3N2 & 34 B) tested for zanamivir resistance to date were sensitive to zanamivir. Oseltamivir resistance findings from Provincial laboratories:
To date this season, 46 influenza isolates in BC have been sub-typed as A/H1 and were assessed genotypically for oseltamivir resistance using an SNP assay. Fourty-two isolates tested positive for the H274Y mutation (resistance = 100% or 42/42), with the other 4 specimens still pending confirmatory testing. Influenza-associated Paediatric Hospitalizations:
In week 02, one laboratory-confirmed influenza-associated paediatric hospitalization (from QC) due to influenza A infection was reported through the Immunization Monitoring Program Active (IMPACT) network. To date, 20 hospitalizations have been reported of which half (50%) have been due to influenza A and half due to influenza B. The proportion of cases to date by age group are as follows: 15% were 0-5 month olds; 20% were 6-23 month olds; 25% were 2-4 year-olds; 15% were 5-9 year-olds; and 25% were 10-16 year-olds.
*** Due to technical difficulties with IMPACT's electronic reporting system, reports of hospitalizations were not received until this week. Over the next several weeks, more retrospective reports of cases may be reported. The first hospitalization for the 2008-2009 season occurred in late November 2008. To date, cases have been reported in QC, ON, AB & BC. International:
CDC: During week 01, overall influenza activity in the United States remained relatively low but increased compared to previous weeks. More states reported widespread, regional and local influenza activity compared to previous weeks. Of the 3,394 specimens tested this week for influenza viruses, 242 (7.1%) were positive. Since 1 October 2008, the CDC has antigenically characterized 158 influenza viruses: 93 influenza A(H1) (all A/Brisbane/59/2007-like), 13 A(H3) (all A/Brisbane/10/2007-like) and 52 influenza B (17 were B/Florida/04/2006-like belonging to the B/Yamagata lineage and the other 35 belonged to the B/Victoria lineage). Since 1 October, 2008, 187 influenza viruses (103 A(H1N1), 23 A (H3N2), and 61 B) have been tested for resistance to neuraminidase inhibitors. Of the A(H1N1) viruses tested, 98% (101/103) were resistant to oseltamivir however all were sensitive to zanamivir. All of the A(H3N2) and B viruses tested were sensitive to both oseltamivir and zanamivir. The CDC tested 126 influenza A viruses (103 H1, 23 H3) for amantadine resistance: only one of the H1N1 viruses was resistant to amantadine (1%, 1/103) however all the H3N2 viruses (100%) were resistant.
EISS: Influenza activity continued to intensify and spread across Europe with most countries now reporting medium to high intensity with a west-to-east spread being observed. Influenza A(H3) viruses continue to predominate. With the exception of the few B/Victoria lineage viruses, the viruses circulating in Europe are similar to the strains included in the current influenza vaccine. Of the 89 A(H3N2) isolates that were tested for adamantanes susceptibility, 88 (99%) were resistant. Of the 60 A(H1N1) virus isolates tested for resistance against neuraminidase inhibitors, 59 (98%) were resistant to oseltamivir, but all were sensitive to zanamivir.
Human Avian Influenza: Since 17 January 2009, the WHO has reported 5 new cases of human H5N1 avian influenza infection. Three cases were reported from China (all from different provinces) of which 1 died; and 2 cases were reported from Indonesia (also from different provinces) of which both died.
Total number of influenza tests performed and number of positive tests by province/territory of testing laboratory, Canada, 2008-2009
Province of
reporting
laboratories
Report Period:
January 11, 2009 to January 17, 2009
Season to Date:
August 24, 2008 to January 17, 2009
Total #
Influenza
Tests
# of Positive Tests
Total #
Influenza
Tests
# of Positive Tests
Influenza A
Influenza B
Total
Influenza A
Influenza B
Total
NL
13
0
0
0
218
0
0
0
PE
7
0
1
1
70
0
1
1
NS
38
1
0
1
323
2
0
2
NB
55
4
0
4
281
5
0
5
QC
963
26
2
28
8918
91
7
98
ON
1187
23
51
74
11296
67
169
236
MB
59
0
1
1
998
0
2
2
SK
191
2
0
2
1779
5
0
5
AB
503
34
2
36
9410
92
66
158
BC
95
22
1
23
839
73
4
77
Canada
3111
112
58
170
34132
335
249
584
Specimens from NT, YT, and NU are sent to reference laboratories in other provinces. Note: Cumulative data includes updates to previous weeks; due to reporting delays, the sum of weekly report totals do not add up to cumulative totals. Abbreviations: Newfoundland/Labrador (NL), Prince Edward Island (PE), New Brunswick (NB), Nova Scotia (NS), Quebec (QC), Ontario (ON), Manitoba (MB), Saskatchewan (SK), Alberta (AB), British Columbia (BC), Yukon (YT), Northwest Territories (NT), Nunavut (NU) Respiratory virus laboratory detections in Canada, by geographic regions, are available weekly on the following website:
<http://www.phac-aspc.gc.ca/bid-bmi/dsd-dsm/rvdi-divr/index-eng.php>
Number of influenza surveillance regions† reporting widespread or localized influenza activity, Canada, by report week, 2008-2009 (N=54)
† sub-regions within the province or territory as defined by the provincial/territorial epidemiologist. Graph may change as late returns come in.
Influenza Activity Level by Provincial and Territorial
Influenza Surveillance Regions, Canada,
January 11, 2009 to January 17, 2009 (Week 02)
Influenza tests reported and percentage of tests positive, Canada, by report week, 2008-2009
Percent positive influenza tests, compared to other respiratory viruses, Canada, by reporting week, 2008-2009
Influenza strain characterization, Canada, cumulative, 2008-2009 influenza season by the Respiratory Viruses Section at the National Microbiology Laboratory
[N=69]
{Strain characterization, number identified, per cent of total number} NACI recommends that the trivalent vaccine for the 2008-2009 season in Canada contain
A/Brisbane/59/2007 (H1N1)-like virus; an A/Brisbane/10/2007 (H3N2)-like virus; and a B/Florida/4/2006-like virus.
Influenza-like illness (ILI) consultation rates, Canada, by report week,
2008-2009 compared to 1996/97 through to 2007/08 seasons
Note: No data available for mean rate in previous years for weeks 19 to 39 (1996-1997 through 2002-2003 seasons).
Number of New Outbreaks in Long Term Care Facilities, Canada, by Report Week, 2008-2009
Fourty-two isolates tested positive for the H274Y mutation (resistance = 100% or 42/42), with the other 4 specimens still pending confirmatory testing.
all of the A/H1N1 isolates were resistant to oseltamivir due to the H274Y mutation (resistance = 100% or 15/15). The resistant isolates were from NS, ON, AB and BC.
A spokesman for the Centre for Health Protection (CHP) of the Department of Health today (January 24) said three of the 18 students and the group leader who returned from Chengdu yesterday developed symptoms compatible with influenza infection.
CHP investigation revealed that the four people, comprising two male and two female aged between 18 and 27, developed fever, sore throat, cough and runny nose.
They have been admitted to the Princess Margaret Hospital in stable condition.
Two of the four specimens taken from them showed positive result for influenza A (H1).
All specimens showed negative result for influenza H5.
The laboratory results showed that they were suffering from ordinary seasonal influenza and not avian influenza H5.
They are among a delegation from the Chinese University of Hong Kong which left for Sichuan on January 17.
The remaining 15 students do not have any symptoms of influenza infection.
-
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
Monday, January 26, 2009
DAVE PARKS
News staff writer
Some of the first influenza cases in Jefferson County this season are being reported by public health officials. And it appears that the type of flu circulating in the area may be resistant to the most commonly used and effective antiviral medicine, Tamiflu.
Dr. Charles H. Woernle, assistant state health officer for Disease Control and Prevention for the Alabama Department of Public Health, said last week that the department confirmed three cases of flu in Jefferson County for the week of Jan. 11-17.
There were no cases confirmed the previous week, and there has been little influenza activity reported statewide this 2008-09 season.
"It has been pretty quiet so far, with a suggestion that it may be picking up," Woernle said.
The Centers for Disease Control recently reported that even though the United States seems to be having a mild flu season, some states have noticed that the prevalence of Type A (H1N1) influenza is showing resistance to the drug oseltamivir, or Tamiflu.
And early testing in Jefferson County shows this is the type of flu that is circulating in the area, Woernle said.
Given the situation, the CDC is recommending using a combination of oseltamivir (Tamiflu) and rimantadine (Flumadine) when treating or trying to prevent H1N1 flu. Another medication, zanamivir (Relenza) is also appropriate for treating H1N1 flu, according to the CDC's recommendation.
Authorities say the best protection against the flu is prevention with vaccination, and there is still time to get a flu shot this season.
James and Diana Noah, two influenza scientists at Southern Research Institute, said it is not unusual for flu viruses to develop resistance to antiviral drugs such as Tamiflu. A flu virus has a natural tendency to mutate quickly.
"When it reproduces it inherently includes mistakes that in some cases cause the virus to die, but in very few cases will grant a selective benefit to the virus," he said. "This is called selective pressure.
"So when a drug is applied, a virus begins churning out genetic mutations until it finds a way to replicate in the presence of the drug.
Diana Noah noted that overprescribing an antiviral drug worsens the problem, and Tamiflu has been used in large quantities in Asia in recent years to prevent or treat influenza.
"The result is you are constantly pressuring the virus, so it makes the changes," she said.
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
Membro del Comitato Consultivo, Editore e Direttore del Forum Italiano di FluTrackers
Join Date: Dec 2007
Location: PADUA
Posts: 12,355
Re: Seasonal Flu 2008 - 2009
Quote:
Originally Posted by tropical
#319: "They have been admitted to the Princess Margaret Hospital in stable condition.
Two of the four specimens taken from them showed positive result for influenza A (H1)."
Seems that A1H1 realy gained more toughness if these folks must be admitted to the hospital.
Last year some people (most young) were admitted at HK hospitals even with serious complications such as encephalitis, miocarditis, pneumonia, etc.
Readers may found further information in archived HK epi-surveillance.
__________________
GIMI69 (IRONOREHOPPER)
--
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
James and Diana Noah, two influenza scientists at Southern Research Institute, said it is not unusual for flu viruses to develop resistance to antiviral drugs such as Tamiflu. A flu virus has a natural tendency to mutate quickly.
"When it reproduces it inherently includes mistakes that in some cases cause the virus to die, but in very few cases will grant a selective benefit to the virus," he said. "This is called selective pressure.
"So when a drug is applied, a virus begins churning out genetic mutations until it finds a way to replicate in the presence of the drug.
Diana Noah noted that overprescribing an antiviral drug worsens the problem, and Tamiflu has been used in large quantities in Asia in recent years to prevent or treat influenza.
"The result is you are constantly pressuring the virus, so it makes the changes," she said.
Seems to me (maybe I'm wrong) that we take in 2009 to be usual things that 10 years ago was rare.
If we read some public reports (US), ita./... investigation initiatives, and look at the recent "Voyager" (RAI2TV/10.00h/Sunday25.1.), we (can...) doubt about the purity of the air we breath.
Dr. Niman remark (#323) point (as previously stated at FT) at the news text which wrongly linked Tamiflu prescripted to humans versus increasing A1H1 resistance.
So, what's going on, earth wide maverick experiments?
Global Trend of Influenza-like Illness (ILI) Morbidity.
Season 2008/2009. Tables and graphs are available in original at web site of the ''Centro Interuniversitario per lo Studio dell'Influenza'' (in Italian) (CIRI)
Data showes influenza-like illnesses incidence among population, based on information collected by family doctors network participants to surveillance activities
Incidence is intended for 1,000 inhabitants and is tabulated according influenza season, surveillance week and class-age.
Influenza-like illness activity continues to rise and the highest value is associated to 0-4 years-old class-age population with an incidence of 16.73x1,000 (1,673 per 100,000). Population in 65+ years-old class-age reports the lowest value (2.14x1,000).
-
-----
__________________
GIMI69 (IRONOREHOPPER)
--
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
Thirty-eight influenza A (H1) specimens have
been tested for anti-viral drug resistance, 37 of these were resistant to oseltamivir and all were sensitive to zanamivir
Thirty-eight influenza A (H1) specimens have
been tested for anti-viral drug resistance, 37 of these were resistant to oseltamivir and all were sensitive to zanamivir
and amantadine.
Canada:
Fiftyseven
influenza A (H1N1) isolates have been tested and
found to be resistant to oseltamivir.
This summary provides an updated report of seasonal influenza activity for weeks 1-2 of 2009. It does not include reports of avian influenza in humans, which are available at: http://www.who.int/csr/disease/avian.../en/index.html
Seasonal influenza activity in the world, weeks 1-2 (as of 23 January 2009)
During the weeks 1-2, the level of overall influenza activity in the world increased. In Europe, widespread influenza activity was reported in 13 countries, regional activity in two countries as well as Wales in the United Kingdom of Great Britain and Northern Ireland, local activity in two countries and sporadic activity in 5 countries and one part of the United Kingdom (Scotland). Eight of the nine countries reporting low influenza intensity are located in the eastern and north-eastern part of Europe. The predominant influenza virus circulating in Europe is influenza A (H3). In Canada, Hong Kong Special Administrative Region of China and the United States of America overall influenza activity remained relatively low. Austria: Influenza activity increased from sporadic to regional activity (A). Belgium: Activity increased from sporadic to widespread (H3). Bulgaria: Influenza activity has been reported for the first time. Canada: During week 1, influenza activity in Canada remained low overall with the majority of the influenza surveillance regions still reporting no activity. The majority of influenza virus detections were influenza A viruses; however influenza B detections have slowly increased over the last several weeks. Denmark: Widespread influenza A H3 activity has been reported. France: Widespread influenza A H3 activity has been reported. Some influenza B viruses have also been detected. Germany: Influenza activity has increased from sporadic to regional (H3). Greece: Influenza activity has increased (H3). Ireland: Continuing widespread influenza A activity has been reported. Italy: Widespread influenza activity reported (H3). Luxembourg: Activity increased from sporadic to widespread (H3). Netherlands: Widespread influenza activity reported (H3). Norway: Influenza activity increased from sporadic to widespread (H3). Poland: Influenza activity has increased (H3). Portugal: The H3 epidemic has passed its peak (week 52). Slovenia: Influenza activity increased from sporadic to widespread (H3). Spain: Influenza activity has increased to widespread (H3). Sweden: Activity increased to widespread (A). Switzerland: Activity increased from regional to widespread (H3). United Kingdom of Great Britain and Northern Ireland: Regional influenza activity was reported for Wales while activity in England and Ireland was widespread (mainly influenza A H3 detected with low numbers of H1N1 and B). Northern Ireland reported widespread influenza activity (H3). United States of America: Overall influenza activity in the United States increased slightly compared to previous weeks. The majority of the viruses detected have been influenza A with A(H1N1) predominating.
Sporadic influenza activity was observed in Brazil (A), Cameroon (H1, H3, B), China (H1, H3, B), China Hong Kong Special Administrative Region (H1,H3,B), Croatia (H1,H3,B), Czech Republic (H3), Estonia (H1,H3, B), Latvia (H1,H3, B), Mongolia (H1, H3, B), Romania (H1,H3, B), Russian Federation (H1,H3,B), Serbia (H1, H3, B).
Kazakhstan and Turkey reported no activity.
[Original PDF Document (in Italian) at : LINK. EDITED. Translated by IOH]
This week there is an important update about surveillance activities performed by National Influenza Centre (NIC) for antiviral resistance evaluation of viral isolates.
-- ITALY
During this surveillance week 178 clinical samples have been collected, of these 39 were influenza positive.
Among them, 38 type A viruses have been isolated and / or detected, 18 type A H3, 1 H1, from Padua University.
An additional type B virus has been isolate by Parma University laboratory.
The table below showes virological surveillance results since the start of season (week 46-08) until date (week 4-09).
Note: differences between this report and previous week one are due to further characterization / isolation activities.
-- FROM THE WORLD
- EUROPE
Influenza virus circulation continues to rise. Viruses Type A/H3 are at the moment the predominant strains.
During this week 3029 clinical samples have been collected. Of these1710, (56%), were influenza positive: 1663 were type A (677 type H3, 37 type H1 and the remaining 949 not yet subtyped).
47 were influenza viruses type B.
Virus isolation and characterization demonstrated that all circulating strains to date were closely related to seasonal influenza vaccine reference strains, with the exception of some influenza B belonging to B/Victoria lineage, not included in this season vaccines.
FIRST ISOLATION IN ITALY OF INFLUENZA A/(H1N1) VIRUSES RESISTANT TO OSELTAMIVIR (2008/2009 Season).
During last surveillance week, Parma's University detected first FIVE A/(H1N1) influenza virus isolations for this season in Italy.
From the analysis performed by NIC, ALL OF THEM WERE OSELTAMIVIR RESISTANT (IC50 value very high); while resistant to oseltamivir, these viruses remained susceptible to Zanamivir.
Corresponding clinical samples were collected at Parma, during week 03/2009, from three children and two adults respectively.
Among these patients, three received this season influenza vaccine, while none of them were treated with oseltamivir.
Full genetic sequencing is undergoing both for HA and NA gene segments of these isolates.
In other EU Member States A/H1N1 viral strains demonstrated an high level of oseltamivir resistance (more than 97%) as well.
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
Membro del Comitato Consultivo, Editore e Direttore del Forum Italiano di FluTrackers
Join Date: Dec 2007
Location: PADUA
Posts: 12,355
Re: Seasonal Flu 2008 - 2009
From post 329:
''ALL OF A/(H1N1) VIRAL SAMPLES ISOLATED SO FAR IN ITALY WERE OSELTAMIVIR RESISTANT (IC50 value very high) [phenotypic test]; while resistant to oseltamivir, these viruses remained susceptible to Zanamivir.
(...)
__________________
GIMI69 (IRONOREHOPPER)
--
People come and go, but the creative force of great historical events, as well as important ideas and actions remain. (Aleksandr Romanovic Lurija, 1976)
-- A TIME'S MEMORY (Blog) ATTRAVERSO QUESTI GIORNI (Blog) tracciatore_traccia@libero.it
The reader is responsible for discerning the validity, factuality or implications of information posted here, be it fictional or based on real events. Moderators on this forum make every effort to review the material posted on this site however, it is not realistically possible for our staff to manually review each post.
The content of posts on this site, including but not limited to links to other web sites, are the expressed opinion of the original authors or posters and are not endorsed by, or representative of the opinions of, the owners or administration of this website. The posts on this website are the opinion of the specific author or poster and should not be construed as statements of advice or factual information.
Not all posts on this website are intended as truthful or factual assertion by their authors. NO posts on this website should be considered factual information on face value alone. Users are encouraged to USE DISCERNMENT and do their own follow up research while reading and posting on this website. FluTrackers.com Inc. reserves the right to make changes to, corrections and/or remove entirely at any time posts made on this website without notice. In addition, FluTrackers.com Inc. disclaims any and all liability for damages incurred directly or indirectly as a result of a post on this website.
This site is provided "as is" without warranty of any kind, either expressed or implied. You should not assume that this site is error-free or that it will be suitable for the particular purpose which you have in mind when using it. In no event shall FluTrackers.com Inc. be liable for any special, incidental, indirect or consequential damages of any kind, or any damages whatsoever, including, without limitation, those resulting from loss of use, data or profits, whether or not advised of the possibility of damage, and on any theory of liability, arising out of or in connection with the use or performance of this site or other documents which are referenced by or linked to this site.
Finally, FluTrackers.com Inc. reserves the right to delete, correct, or make changes to any post on this website without notice at any time for any reason.
Fair Use Notice:
This site may contain copyrighted material the use of which has not always been specifically authorized by the copyright owner. Users may make such material available in an effort to advance awareness and understanding of issues relating to public health, civil rights, economics, individual rights, international affairs, liberty, science & technology, etc. We believe this constitutes a 'fair use' of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C.Section 107, the material on this site is distributed to those who have expressed a prior interest in receiving the included information for research and educational purposes.
In accordance with industry accepted best practices we ask that users limit their copy / paste of copyrighted material to the relevant portions of the article you wish to discuss and no more than 50% of the source material, provide a link back to the original article and provide your original comments / criticism in your post with the article. Please remember you are responsible for what you post on the internet and you could be sued by the original copyright holder if you do not honor these rules.
If you are a legal copyright holder or a designated agent for such and you believe a post on this website falls outside the boundaries of "Fair Use" and legitimately infringes on yours or your clients copyright
we may be contacted concerning copyright matters at:
FluTrackers.com Inc.
c/o Sharon Sanders
1676 Hibiscus Avenue
Winter Park, Florida 32789
Phone: 407-406-3037
E-Mail: flutrackers@earthlink.net
In accordance with section 512 of the U.S. Copyright Act our contact information has been registered with the United States Copyright Office. "Safe Harbor" noticing procedures as outlined in the DMCA apply to this website concerning all 3rd party posts published herein.
If notice is given of an alleged copyright violation we will act expeditiously to remove or disable access to the material(s) in question.
All 3rd party material posted on this website is the copyright of the respective owners / authors. FluTrackers.com Inc. makes no claim of copyright on such material.
For more information please visit:
http://www.law.cornell.edu/uscode/17/107.shtml
Please be aware any communications sent complaining about a post on this website may be posted publicly at the discretion of the administration.
FluTrackers Does Not Provide Any Medical Advice:
FluTrackers, Inc. does not provide medical advice. Information on this web site is collected from various internet resources, and the FluTrackers board of directors makes no warranty to the safety, efficacy, correctness or completeness of the information posted on this site by any author or poster.
The information collated here is for instructional and/or discussion purposes only and is NOT intended to diagnose or treat any disease, illness, or other medical condition. Every individual reader or poster should seek advice from their personal physician/healthcare practitioner before considering or using any interventions that are discussed on this website.
By continuing to access this website you agree to consult your personal physican before using any interventions posted on this website, and you agree to hold harmless FluTrackers.com Inc., the board of directors, the members, and all authors and posters for any effects from use of any medication, supplement, vitamin or other substance, device, intervention, etc. mentioned in posts on this website, or other internet venues referenced in posts on this website.
By using and/or accessing this site, either passively or actively, you are agreeing to all of the above conditions. Also, by using and/or accessing this site, either passively or actively, you agree to conduct all business and legal affairs related to this website in the jurisdiction of Flutrackers.com Inc. which is registered in Central Florida, USA.
These Disclaimers are subject to change at anytime.
Email the Webmaster with questions or comments about this site at flutrackers@earthlink.net
Re: Seasonal Flu 2008 - 2009
Linear Mode
