EISS - Weekly Electronic Bulletin Week 49 : 01/12/2008-07/12/2008 - 12 December 2008, Issue N° 283 - Influenza activity in Europe remains low but steadily rising – more countries report initial virus detections § Summary:
A total of 23 countries reported influenza activity in week 49/2008. This activity was low in all but three countries where medium activity was recorded. Since week 40/2008, sporadic laboratory-confirmed cases of influenza have been reported from 23 countries across Europe. Two of these countries, neighbouring, are now reporting local outbreaks (Spain) and widespread increased influenza activity above baseline levels (Portugal).
§ Epidemiological situation - week 49/2008:
For the intensity indicator, the national network levels of influenza-like illness (ILI) and/or acute respiratory infection (ARI) were low in 20 of the 23 countries providing data, with Ireland, Northern Ireland and Portugal reporting medium intensity.
Eight countries, however, reported increasing clinical activity (England, Ireland, Latvia, Netherlands, Northern Ireland, Portugal, Spain, Wales), but only for England, Ireland, Netherlands, Northern Ireland and Portugal was this elevated compared to the 2007-8 season.
For the geographical spread indicator, sporadic influenza activity was reported in 11 countries (Bulgaria, Denmark, England, Germany, Hungary, Ireland, Luxembourg, Northern Ireland, Slovenia, Sweden and Switzerland) whereas Spain reported local outbreaks and Portugal widespread increased influenza activity above baseline levels.
The other ten countries reported no activity.
§ Cumulative epidemiological situation – 2008-2009 season (weeks 40-49/2008):
So far this season, the consultation rates for ILI and/or ARI are generally at levels usually seen outside the winter period (i.e. below the national baseline threshold).
§ Virological situation - week 49/2008:
The total number of respiratory specimens collected by sentinel physicians in week 49/2008 was 615, of which 118 (19.2%) were positive for influenza virus: 114 type A (85 subtype H3, one H1 and 28 not subtyped) and four type B.
In addition, from 665 non-sentinel source specimens (e.g. specimens collected for diagnostic purposes in hospitals) 96 (14.4%) influenza virus detections were reported: 92 type A (11 subtype H3, three subtype H1 and 78 not subtyped) and four type B.
Detection of influenza viruses was reported from 15 countries across Europe and included the first influenza detections from Bulgaria, Luxembourg and Slovenia.
§ Cumulative virological situation – 2008-2009 season (weeks 40-49/2008):
Of 668 virus detections (sentinel and non-sentinel) since week 40/2008, 621 were type A (317 subtype H3, 26 subtype H1 and 278 not subtyped) and 47 were type B.
Based on the antigenic and/or genetic characterisation of 106 influenza viruses, 100 were reported as A/Brisbane/10/2007 (H3N2)-like, two as A/Brisbane/59/2007 (H1N1)-like, two as B/Malaysia/2506/2004-like (B/Victoria/2/87 lineage) and two as B/Florida/4/2006-like (B/Yamagata/16/88 lineage).
No additional antiviral resistance data has been uploaded in the last week so the situation is as reported in week 48/2008.
Data from Austria, England and Norway shows most (18/19) of the A (H1N1) viruses analysed to be oseltamivir-resistant with all 19 remaining sensitive to zanamivir.
Of 27 A (H3N2) viruses analysed for neuraminidase inhibitor susceptibility, all are sensitive to both oseltamivir and zanamivir.
Of 26 A (H3N2) viruses analysed for adamantane susceptibility, all are resistant.
Most circulating influenza A at present is H3N2 that remains fully sensitive to oseltamivir and zanamivir.
§ Comment:
Many countries reporting influenza virus detection continue to classify this as sporadic with only Spain (local) and Portugal (widespread) changing their classifications, although this has not been accompanied by significant increases in overall consultation rates.
Of the eight countries that reported increasing clinical activity during week 49/2008, six (England, Ireland, Northern Ireland, Portugal, Spain and Wales) also reported influenza virus detections.
The 23 countries that have detected influenza viruses since week 40/2008 are geographically distributed throughout Europe.
The majority (93%; 621/668) of virus detections up to week 49 have been type A.
The cumulative proportion of type A viruses subtyped as H3 has increased from 90% (205/228) at week 48 to 92.4% (317/343) at week 49.
Virological subtype analysis indicates that whilst there is mixed circulation of H1 and H3 in countries reporting isolates, the H1 detections have been made at a stable rate of one to five per week since week 40 whereas H3 detections have been rising consistently since week 41 to reach 96 in week 49.
This is an early indication of the 2008-9 influenza season in Europe being dominated by H3.
Whilst influenza activity in Europe remains low currently, Respiratory Syncytial Virus (RSV) infections induce clinical symptoms similar to influenza. Earlier weekly reports of RSV detections from countries in Europe that report RSV detections to EISS, showed increased detections in a number of countries which have now stabilised or declined in all but the Netherlands.
Increase in RSV detections at this time of the year is a normal phenomenon in these countries.
§ Background:
The Weekly Electronic Bulletin presents and comments on influenza activity in the 30 European countries that are members of EISS. Of these countries, 23 reported clinical data, 26 virological data and 22 both data sets to EISS in week 49/2008.
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).
§ Map
The map presents the intensity of influenza activity and the geographical spread as assessed by each of the networks in EISS.
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 witha 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 inSouth-Western Finland (the health-care district serves 54,000 inhabitants i.e. approximately onepercent of the Finnish population).
§ Network comments (where available) -- Italy: Only one A/H3N2 influenza viruses have been isolated during this week. -- Switzerland: Influenza activity is very low. An influenza B virus has been detected last week.
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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
2008-2009 Influenza Season Week 49 ending December 6, 2008 (All data are preliminary and may change as more reports are received.) Synopsis:
During week 49 (November 30-December 6, 2008), a low level of influenza activity was reported in the United States.
Seventy-two (2.8%) 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.
The proportion of outpatient visits for influenza-like illness (ILI) was below national and region-specific baseline levels.
Three states reported local influenza activity; the District of Columbia, Puerto Rico and 24 states reported sporadic influenza activity; and 23 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
2.8 %
0 of 51
157
18
233
99
0
New England
Normal
0.7 %
0 of 6
0
1
6
1
0
Mid-Atlantic
Normal
0.3 %
0 of 3
3
0
3
2
0
East North Central
Normal
3.4 %
0 of 5
6
1
4
6
0
West North Central
Normal
0.0 %
0 of 7
0
0
6
5
0
South Atlantic
Normal
2.3 %
0 of 9
7
0
66
35
0
East South Central
Normal
0.5 %
0 of 4
0
0
0
1
0
West South Central
Normal
3.5 %
0 of 4
25
0
71
33
0
Mountain
Normal
3.3 %
0 of 8
5
11
16
5
0
Pacific
Normal
3.6 %
0 of 5
111
5
61
11
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. Results of these tests performed during the current week and cumulative totals for the season are summarized in the table below.
Week 49
Cumulative for the Season
No. of specimens tested
2585
31394
No. of positive specimens (%)
72 (2.8%)
507 (1.6%)
Positive specimens by type/subtype
Influenza A
62 (86.1%)
408 (80.5%)
A (H1)
12 (19.4%)
157 (38.5%)
A (H3)
3 (4.8%)
18 (4.4%)
A (unsubtyped)
47 (75.8%)
233 (57.1%)
Influenza B
10 (13.9%)
99 (19.5%)
Thirty states from all nine surveillance regions have reported laboratory-confirmed influenza this season with three states accounting for 392 (77.3%) of the 507 reported influenza viruses.
CDC has antigenically characterized 36 influenza viruses [20 influenza A (H1), three influenza A (H3) and 13 influenza B viruses] collected by U.S. laboratories since October 1, 2008.
All influenza A (H1) viruses were characterized as A/Brisbane/59/2007-like and all influenza A (H3) viruses were characterized as A/Brisbane/10/2007-like, the influenza A (H1N1) and influenza A (H3N2) components included in the 2008-09 influenza vaccine.
Influenza B viruses currently circulating can be divided into two antigenically distinct lineages represented by the B/Yamagata/16/88 and B/Victoria/02/87 viruses. Four influenza B viruses were characterized as B/Florida/04/2006-like, belonging to the B/Yamagata lineage, the influenza B component of the 2008-09 influenza vaccine. The remaining nine viruses belong to the B/Victoria lineage. Eight of the nine viruses belonging to the B/Victoria lineage were from one state.
Data on antigenic characterization should be interpreted with caution given that:
Few U.S. isolates are available for testing because of limited flu activity thus far.
The majority of viruses antigenically characterized to date come from only two states and may not be nationally representative.
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 which are most similar to the vaccine strains, but can also provide at least partial protection against strains that are related, but antigenically distinct from vaccine strains. 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, 46 influenza A (H1N1), seven influenza A (H3N2), and 15 influenza B viruses from 15 states have been tested for antiviral resistance; however, 63% of the viruses tested were from only two states. Forty-five of 46 influenza A (H1N1) viruses tested were resistant to oseltamivir; while all 46 viruses were sensitive to zanamivir. All influenza A (H3N2) and B viruses tested were sensitive to oseltamivir and zanamivir.
Twenty-five influenza A (H1N1) and five influenza A (H3N2) viruses were tested for adamantane resistance. All influenza A (H1N1) viruses were sensitive to the adamantanes. All influenza A (H3N2) viruses tested were resistant to the adamantanes. The adamantanes are not effective against influenza B viruses.
Three states have reported local influenza activity during the 2008-09 season in the United States to date, thus the number of virus specimens available for antiviral resistance testing is limited in both the overall number tested and in the number of states that have submitted specimens. Limited data on antiviral resistance, as well as the uncertainty regarding which influenza virus types or subtypes will circulate during the season, make it too early to make an accurate determination of the prevalence of influenza viruses resistance to oseltamivir or the adamantanes (amantadine and rimantadine) nationally or regionally at this time. CDC has solicited a representative sample of viruses from WHO collaborating laboratories in the United States, and more specimens are expected as influenza activity increases. Pneumonia and Influenza (P&I) Mortality Surveillance
During week 49, 6.5% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage is below the epidemic threshold of 7.2% for week 49.
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.
EIP Influenza Laboratory-Confirmed Hospitalization rates as of week 49,
2005-06, 2006-07, 2007-08, and 2008-09 seasons
During week 49, 1.3% of patient visits reported through the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) (formerly known as the U.S. Influenza Sentinel Provider Surveillance Network) 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 0.4% to 1.9%. All nine regions reported percentages of visits for ILI below their respective region-specific baselines.
During week 49 the following influenza activity was reported:
Local influenza activity was reported by three states (Hawaii, Massachusetts, and Texas).
Sporadic activity was reported in the District of Columbia, Puerto Rico, and 24 states (Alaska, Arizona, California, Colorado, Connecticut, Florida, Idaho, Illinois, Indiana, Maryland, Michigan, Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Utah, West Virginia, Washington, and Wisconsin).
No influenza activity was reported in 23 states (Alabama, Arkansas, Delaware, Georgia, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Vermont, Virginia, and Wyoming).
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A description of surveillance methods is available at: http://www.cdc.gov/flu/weekly/fluactivity.htm
Dec 12, 2008 (CIDRAP News) – With this year's US influenza epidemic barely getting started, there are already signs of increased viral resistance to oseltamivir (Tamiflu), the most widely used antiviral drug, the Centers for Disease Control and Prevention (CDC) said today.
In its flu surveillance report for Nov 30 to Dec 6, released today, the CDC said 45 of 46 influenza A/H1N1 viruses tested so far have shown resistance to oseltamivir.
All the H1N1 viruses were susceptible to zanamivir (Relenza), the other antiviral drug in the neuraminidase inhibitor class, the agency reported. All tested influenza A/H3N2 and B viruses were susceptible to both oseltamivir and zanamivir. Sixty-three percent of all the viruses tested came from only two states.
The CDC said all the H1N1 viruses also were susceptible to the adamantanes (amantadine and rimantadine), the older class of flu antivirals. However, 5 of 5 H3N2 viruses tested were resistant to the adamantanes (which do not work against type B viruses). The CDC has been recommending against using the adamantanes since January 2006 because of high resistance rates in H3N2 viruses.
With only three states reporting more than scattered flu cases so far, the CDC said it's too early to assess how common resistance to either class of drugs will be.
"Limited data on antiviral resistance, as well as the uncertainty regarding which influenza virus types or subtypes will circulate during the season, make it too early to make an accurate determination of the prevalence of influenza viruses' resistance to oseltamivir or the adamantanes . . . nationally or regionally at this time," the report said.
Increased H1N1 resistance to oseltamivir cropped up during the last flu season in the United States and a number of other countries. By the end of the season, 10.9% (106 of 969) of H1N1 viruses tested had shown the mutation associated with resistance, the CDC reported in May. All the isolates remained sensitive to zanamivir.
After the resistance problem emerged last winter, the World Health Organization said there was no evidence that the resistant H1N1 viruses caused more severe illness or spread more easily than susceptible H1N1 viruses.
In its update today, the CDC said only Hawaii, Massachusetts, and Texas reported local flu activity in early December. Another 24 states, with Washington, DC, and Puerto Rico, reported sporadic cases, and 23 states reported no flu activity.
In addition, only 1.3% of patient medical visits reported through the CDC's Outpatient Influenza-like Illness Surveillance Network were due to flu-like illness, which is well below the national baseline of 2.4%, the agency said.
The CDC said it has tested 36 isolates so far to determine how well they match up with the strains used in this year's flu vaccine. The 20 H1N1 and 3 H3N2 isolates tested were all found to be similar to the corresponding strains in the vaccine.
Of the 13 type B isolates tested, 4 belonged to the Yamagata lineage, the type used in the vaccine. However, the other 9 B isolates—8 of which were from one state—belonged to the Victoria lineage, the CDC said.
The agency said "limited to no protection" may be expected when the circulating and vaccine strains belong to different lineages. However, it said the data available so far must be interpreted cautiously because so few isolates were tested and most of them came from only two states. Also, the report said, the results may not correlate with clinical protection conferred by the vaccine because the testing involves ferret serum.
The B strain in the seasonal vaccine was changed from the Victoria lineage to the Yamagata lineage for this season. The switch was prompted by a mismatch last year, when most of the type B viruses in circulation were of the Yamagata lineage.
The only H1N1 that was NOT Tamiflu resisatnce was in the first report (on two tests). Thus, after the first report, all 44 H1N1 isoaltes tested were Tamiflu resistant. This week's report has almost twice as many isolates tested (it was all 23 in last week's report, which was used for today's MMWR).
This week's data leaves little doubt that H274Y is fixed in H1N1 (in the United States and Europe), yet the CDC maintains its mismatched recommendation (against amantadine, when very few isolates are H3N2, which are 100% amantadine resistant and for Tamiflu, when the vast majority of influenza A is Tamiflu resistant since most are H1N1 and all H1N1 is Tamiflu resistant).
Hospitals forced to close wards as virulent winter bug spreads
Hospitals are facing a winter crisis as a sharp rise in cases of flu and other viruses forces some to close wards to new patients.
By Patrick Sawer
Last Updated: 5:12PM GMT 13 Dec 2008
Several hospitals are already struggling to cope with a sudden rise in admissions and the spread of a virulent winter vomiting bug.
Figures from NHS Direct's telephone help line show that the number of calls about colds, flu, coughs and fever has trebled in the past three months.
The figure tends to rise as winter draws in, but in the same period last year the increase was only two-fold, not three-fold.
NHS Direct received 10,512 calls between September and December this year, compared to 3,435 calls for the previous three months, while more than 25,000 people have visited NHS Direct's flu symptom checker website.
The vomiting bug norovirus – the most common gastrointestinal illness in the UK, affecting up to a million people every year – is causing particular problems, with NHS chiefs forced to warn sufferers to stay away from doctors' surgeries and hospitals for fear of spreading it further.
Affected hospitals include Addenbrooke's in Cambridge, Norfolk and Norwich Hospital, Worcestershire Royal Hospital and York Hospital.
Several trusts said the knock-on effect was making it difficult to meet the Government's target of admitting, or dealing with, 98 per cent of emergency patients within four hours.
One of London's three major trauma centres, St George's in Tooting, was issued a 'black alert' and closed its doors to emergencies for a number of hours on Monday after experiencing a 14 per cent surge in demand compared to the same period last year.
Staff at St George's reported that up to 20 patients requiring urgent admission had to be kept on beds in A&E as wards were full.
Some were diverted to neighbouring hospitals, including Mayday in Croydon, Kingston Hospital and St Helier in Sutton, all of which reported pressure on their own capacity.
The Royal Devon & Exeter Hospital closed its doors to all visitors last week after 12 of its 49 wards were infected, forcing it to postpone about 60 non-urgent operations.
It faced extra pressure from emergency admissions caused by falls on ice, with nearly 100 people going into the emergency department with ice-related injuries on Monday alone.
In Carlisle, two elderly care wards at the Cumberland Infirmary were closed last week in a bid to isolate the norovirus bug. Nearby Wigton cottage hospital was closed to all admissions and non-emergency transfers for the second time in a fortnight.
Two wards at East Surrey Hospital closed, while five at the Queen Elizabeth Hospital in King's Lynn were shut or under observation.
At the University Hospital of North Staffordshire, six wards were closed, reducing the number of beds available to patients by 130.
Sarah Byrom, the chief nurse, said: "While norovirus is common for this time of year, we have seen a big increase in the number of people coming into the hospital with symptoms."
Affected wards can usually be reopened after a few days, following routine disinfecting. But campaigners claim that cuts in bed capacity have left hospitals ill-equipped to cope with seasonal flu, accidents and respiratory complaints at the same time as having to close wards to cope with norovirus.
Geoff Martin, head of campaigns at Health Emergency, called the situation at St George's "deeply worrying" and said: "We are calling on the Government to make cash available to open additional beds and draft in extra staff to cope with the growing crisis on the wards."
Norman Lamb MP, Liberal Democrat spokesman for health, said too many hospitals where operating at 90 to 95 per cent capacity, despite experts recommending no higher than 85 per cent in order to allow hospitals to cope with a sudden influx of patients or an emergency.
He said: "There is a minority of hospitals around the country already operating under impossible pressure and when you add to that winter viruses such as norovirus you get a crisis. It has an impossible impact on staff, putting them under enormous strain, and it clearly affects patient care."
A spokesman for the Department of Health said: "Winter crises used to bedevil the NHS. Thanks to record investment and better organisation we have not had a major winter crisis for several years. However, we constantly update our contingency plans in the light of events."
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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
If the medical services in the UK are having a difficult time handling norovirus and seasonal flu...one has to wonder how they'll do in a H5N1 pandemic...
The region’s hospitals and emergency services dealt with a record numbers of patients calling 999 on Saturday. West Midlands and Staffordshire Ambulance Service’s Brierley Hill control room took 2,146 calls, which is around 650 more than usual. Extra staff were put on to try and cope with the demand but it meant some callers with non-urgent illnesses having to wait longer than usual.
Ambulance spokesman Murray MacGregor said the number of calls was unprecedented.
“We think it is down to a number of things including the flu, the current cold snap, the fact that it is winter and it is coming up to Christmas which is a busy time of year. There is a lot of sickness around at the moment.”
He said people suffering from a winter bug with diarrhoea symptoms should stay home and keep warm and not call the ambulance service unless it is an emergency.
He added: “What is worrying is the very serious calls which could be life threatening are up 20 to 30 per cent.”
In Birmingham, one of the GP out of hours service called Badger, had its busiest day in 12 years, dealing with 2,183 calls in 24 hours.
One of the biggest problems has been a flu-like illness causing respiratory problems and sickness and diarrhoea which has been causing particular problems among older people.
Health chiefs are predicting that demand for NHS services will continue to remain high during the coming days and are calling on people to make sure they get the right kind of treatment and not call an ambulance when their problem can be dealt with by a walk-in health centre.
Rob Ashford, chief operating officer for West Midlands Ambulance Service, said: “We ask people not to call 999 if it is not an emergency but if they are in any doubt, however, patients should dial 999.”
H1N1 Tamiflu Resistance in the United States Increases to 98%
Recombinomics Commentary 13:16
December 15, 2008
Forty-five of 46 influenza A (H1N1) viruses tested were resistant to oseltamivir
Twenty-five influenza A (H1N1) and five influenza A (H3N2) viruses were tested for adamantane resistance. All influenza A (H1N1) viruses were sensitive to the adamantanes. All influenza A (H3N2) viruses tested were resistant to the adamantanes.
Limited data on antiviral resistance, as well as the uncertainty regarding which influenza virus types or subtypes will circulate during the season, make it too early to make an accurate determination of the prevalence of influenza viruses resistance to oseltamivir or the adamantanes (amantadine and rimantadine) nationally or regionally at this time.
The above comments from the week 49 report on influenza in the United States extend and confirm earlier data, and once again highlight the mismatch between the frequencies of antiviral resistance in the US, and the CDC recommendations which discourage use of amantadines and encourage oseltamivir.
Currently amantadine resistance in H3N2 remains at 100%, while similar frequencies (currently 98%) are found for oseltamivir resistance in H1N1.
Most of the influenza in the US is influenza A 408/507, and most of the influenza A is H1N1 (157/175). Last season the level of osletamivir resistance in the US was closer to 10% because clade 2C was in circulation, which had no oseltamivir resistance, but was 100% amantadine resistant. Moreover, most of the oseltamivir resistance (H274Y) in H1N1 was limited to a specific 2B sub-clade.
However, this 2B (Brisbane/59) sub-clade achieved dominance in the southern hemisphere in 2008, and now represents almost all clade 2B in North America and Europe. Thus, now all tested H1N1 in the US and Europe is amantadine sensitive and oseltamivir resistance.
H3N2 has maintained its resistance to amantadine, and in Europe H3N2 is dominant. However, in the US H1N1 is dominant, so the level of oseltamivir resistance is much higher than amantadine resistance, and the CDC recommendations remain mismatched.
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"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
RED figures indicate an increasing in incidence, those in BLUE a decreasing incidence. -
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GIMI69 (IRONOREHOPPER)
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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
INFLUENZA VIROLOGIC SURVEILLANCE - Dec 17 2008Update
Full PDF Document available following this LINK. [Manual translation by IOH]
Weekly Update, week 50/08
ITALY
Influnet network continues to collect samples to test for influenza viruses, despite low influenza activity around Italy. During this surveillance week only ONE virus has been isolated: an influenza A/H3N2 virus, by the laboratory of Rome's Catholic University.
In the table below, are represented the virologic results of the first five weeks of surveillance (weeks 46-08 - 50-08).
N.B. Apparent discrepancies between this week table and last week one could be due to further subtyping analysis undergone by laboratories.
Below Figure represents phylogenetic relationship of HA1 portion of Hemagglutinin of A/H3N2 viruses isolated during this season compared with some of previous influenza season.
Results clearly demonstrate that current A/H3N2 circulating viruses belong to the A/Brisbane/10/2007 lineage, reference strain for this year trivalent inactivated vaccine.
Figure. Phylogenetic relationship of HA1 portion of HA of recenlty A/H3N2 viruses isolated in Italy. Phylogenetic analysis has been done by ISS [National Health Institute], through Neighbor-Joining (MEGA 3.1) algorithm for phylogenetic tree building.
NEWS FROM THE WORLD
Europe
Influenza viruses circulation is increasing, yet at low level, in the most part of surveillance participants countries. During current surveillance week 1280 samples, have been collected, of these, 214 resulted influenza positive.
206 were type A (96 subtype H3, 4 subtype H1 and the remaining 106 A unsubtyped) the remaining were type B.
Of the Influenza viruses further characterized, all demonstrated to be phylogenetically closely related to this season influenza vaccine reference strains.
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
Influenza activity is widespread across parts of the UK and has continued to increase from week 49 to week 50/08. GP consultation rates have increased and have exceeded threshold levels in England, they have also increased but remain within baseline in Scotland and Wales. In Northern Ireland the rate has greatly increased but thresholds have not yet been set. Thresholds for NHS Direct in England and Wales have been exceeded. Of the samples referred to the Centre for Infections' Respiratory Virus Unit (RVU) during week 50/08, 105 were positive for influenza A; four A (H1) and 97 A (H3), and four for influenza B. Other NHS and HPA laboratories in England and Wales reported 109 influenza A and two influenza B positive specimens in week 50/08. Fifteen Scottish and 18 Northern Irish influenza positive specimens were reported in week 50. Seven outbreaks of respiratory illness were reported from various areas of England in an army barracks, care homes and schools in week 50/08. The weekly vaccine uptake rates for the over 65 years increased from 71.4% in week 49/08 to 72% in week 50/08 and in the under 65 years at risk group it increased from 43.4% to 44.2% in the same time period. Influenza activity was at low levels throughout the rest of Europe with 11 countries reporting increasing activity in week 49/08.
Clinical and virological indicators suggest that influenza viruses are now circulating within the community. The department of health now recommend the use of antivirals for treatment and prophylaxis of influenza according to NICE guidance. Further information can be found on the NICE website (http://www.nice.org.uk/Guidance/TA158 ).
Anti-viral susceptibility testing: Neuraminidase inhibitor susceptibility testing on 44A (H3) isolates since week 36/08 showed that all are sensitive to oseltamivir and zanamivir but resistant to amantadine. All of the four influenza B isolates tested since week 36/08 are sensitive to oseltamivir and zanamivir. Twenty-two of 23 A (H1) specimens tested in the same time frame are resistant to oseltamivir but sensitive to zanamivir and amantadine. The majority of these resistant viruses come from the south west of England with the remaining from Wales and northern England. Two influenza A (H1) isolates have been found to be resistant to oseltamivir in Scotland this season.
Membro del Comitato Consultivo, Editore e Direttore del Forum Italiano di FluTrackers
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Re: Seasonal Flu 2008 - 2009
[Despite the current spike in medical assistance requests by British people is driven by several factors, flu is among them. IOH]
Unprecedented winter illness season: public urged to only use 999 for genuine emergencies
Quote:
The public should avoid calling 999 unless it is a genuine emergency as ambulance services and A&E departments struggle to cope with an unprecedented winter illness season, a senior NHS leader warned.
By Rebecca Smith, Medical Editor
Last Updated: 8:13PM GMT 17 Dec 2008
Quote:
Ambulance services in England have just endured their busiest week ever after the coldest start to a winter for 30 years caused a sharp rise in falls and breathing problems.
This, combined with the flu season beginning early and an outbreak of the vomiting bug norovirus, has placed NHS emergency services under intense pressure.
Quote:
Peter Bradley, national director of ambulance services, told The Daily Telegraph that the entire system was “struggling to cope”.
He warned that things would only get worse over the peak season for winter illnesses and accidents of Christmas and New Year due to a surge in drinking related calls on top of the winter illnesses.
Quote:
People are urged not to dial 999 or visit A&E unless it is a genuine emergency.
Mr Bradley, who is also chief executive of London Ambulance Service, which is at ‘critical’ level four on a scale out of five, said:
Quote:
“The increase that has come this winter has been far more dramatic than normal.
“It has been the most difficult ten days I have seen in the last ten years. It is absolutely horrendous.
“Hospitals are full and A&E departments are struggling. We have got ambulances having to wait longer to offload patients and that is causing difficulties.
“The message is that the public really need to do their best to avoid using A&E and ambulance services unless it is a genuine emergency. Use walk-in centres, NHS Direct and pharmacies because the relentless increase in activity will not ease for the next few weeks.”
Officials at the Department of Health are holding crisis talks with NHS managers to find out what can be done before next week when the situation is expected to worsen.
Calls to the ambulance service normally peak over the Christmas and New Year period as the party season coincides with a rise in illness and health workers' annual leave.
But Mr Bradley warned the service was already at breaking point with some areas seeing a 30 per cent rise in calls over the last ten days and hospital A&E departments so full they are turning ambulances away and cancelling operations.
Quote:
Figures from the Royal College of GPs, which monitor common illness in the community, showed a jump of about 20 per cent in consultations over chronic bronchitis, colds, flu and respiratory diseases during the last week.
Ambulance workers are being offered bonuses of between £300 and £800 for doing a month’s worth of overtime, meal breaks have been suspended and private ambulance companies and the St John Ambulance Service are being drafted in to help in some areas.
The Met Office said last week that the UK had seen its coldest start to December since 1976, with the average temperature for the first 10 days of the month only 35.1F (1.7C), well below the long-term 1971-2000 average of 40.5F (4.7C). It comes at the end of a year when energy bills have soared, with many power companies reluctant to pass on recent falls in the price of oil to consumers.
Mr Bradley urged the elderly to try and stay warm but added: “The high power bills are not helping with this.”
Quote:
Critics said the NHS has closed so many beds in recent years that it cannot now cope when there is a rise in demand.
Dr Jonathan Fielden, chairman of the British Medical Association’s consultants committee, said: “We have actually now shrunk the service to a point where we do not have the capacity to flex up during busy periods. We need an urgent review of this system across the country.”
A spokesman for NHS North West said there has been a four per cent increase in emergency admissions last week compared to last year with flu being the main problem. The ambulance service in the north west has also seen a 25 per cent increase in the number of life threatening 999 calls in the last week.
A&E department at St George’s Hospital in Tooting south London has been forced to divert patients this week and managers at Epsom Hospital in south London has asked patient to only visit A&E in an emergency.
Ambulances have been forced to queue up a dozen deep outside the Queen Alexandra Hospital in Cosham, Portsmouth, as the hospital struggles to cope.
The Hull Royal Infirmary has seen a sharp increase in A&E attendances over the last week and managers have asked patients to see their GP with minor illnesses in order to ease pressure on the hospital.
Leighton Hospital in Cheshire was forced to close its A&E on Monday and cancel some operations after the number of emergency admissions doubled although they have now re-opened to new patients.
Figures from West Midlands Ambulance Service show December 8th was busier than New Year’s Eve and overall calls are up 30 per cent on last year.
Quote:
Birmingham’s GP out of hours service saw its busiest day in 12 years on Saturday after being inundated with flu-like illnesses and cases of the norovirus vomiting bug.
A spokesman for NHS London said: “The NHS is used to dealing with the pressures that winter brings and has effective plans in place to deal with these pressures when they arise. As in most years this is not a London-specific problem as there are winter pressures across the country.
We would urge people who are not seriously ill or injured to consider other ways of getting help before calling 999, such as visiting their GP or calling NHS Direct on 0846 4647.”
- http://www.telegraph.co.uk/health/he...ergencies.html
-----
__________________
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 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
Only one A/H3N2 influenza isolate has been reported during this week. Three further A/H3N2 viruses have been isolated from samples collected in week 49. Switzerland
Sporadic influenza activity in Switzerland
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.
Flu bug runs rampant: Worst epidemic for nine years as the rate of infection doubles in a fortnight
By DANIEL MARTIN
19th December 2008
Hospitals and ambulance crews are struggling to cope with Britain's worst flu outbreak for almost a decade.
In some parts of the country more than double the average number of patients are seeing their GPs with flu or the winter vomiting bug.
Ambulance crews warn they will be stretched to 'breaking point' tonight with the combination of sharply rising serious flu cases and the busiest evening for Christmas parties.
The last Friday before Christmas is always the peak day for 999 calls due to over-indulgence at office celebrations. But this year the pressure will be much worse because of the early start to the flu season.
Figures from the Royal College of General Practitioners show the numbers with influenza-like symptoms being seen by GPs is the highest since the last big outbreak in 1999/2000. Then 22,000 died – ten times more than average.
The usual flu rate for the 50th week of the year over the past nine years in England has been around 23 cases per 100,000 population. This year the rate was 39.5.
In the Midlands, it was 56 – more than double the average. And in the south, it was 36.4 per 100,000 people. Only the north of England, with a flu rate of 16.36, is below the average for this time of year.
But in all three areas of England, the number of cases has more than doubled in the past fortnight. However total figures are still much lower than the 1999/2000 outbreak. The coldest December for 30 years is contributing to the rise.
Experts also say it could be down to a new strain of flu, Brisbane H3N2, which infects three times as many people as usual types. Professor John Oxford of St Bartholomew's Hospital in London said: 'You don't have to be a professor of virology to look at these figures and say "Oh God, something very bad is happening".
Secretary of State for Health Alan Johnson accepts that the NHS is under pressure but insists it can cope
'I wouldn't be at all surprised if this is the worst outbreak since 1999/2000 and we will have to work on the assumption that it is. There is a lot happening, especially in the central region where the rises are particularly steep.
'Anyone who is in an at-risk group should go to their GP now to get the jab. There is no shortage of vaccine at the moment. They should take action now to ensure their Christmas isn't ruined by flu.'
The extra demand for help has left the NHS ambulance service stretched to 'breaking point', according to Unison, the leading union for ambulance crews.
'Ambulance crews and A&E departments are under enormous pressure because of accidents and ill-health brought on by the cold weather, and a major rise in cases of flu,' said Sam Oestriecher, Unison's national officer for ambulance workers.
'However, that pressure will be at breaking point tonight, when office Christmas parties hit their peak.
'Many people who would not normally drink too much overdo it and it is the ambulance staff who deal with the consequences. It's hard to believe but it's worse than New Year.'
Yesterday, London Ambulance Service chief executive Peter Bradley said the particularly cold start to winter was also behind a sharp increase in reports of falls and breathing problems.
'It has been the most difficult ten days I have seen in the last ten years,' he said. 'It is absolutely horrendous.'
Health Secretary Alan Johnson denied services were at breaking point. He agreed the Health Service was under pressure but added: 'It is pressure that we can cope with.
Influenza season started in three European countries while more countries report increasing activity Summary: In week 50/2008 influenza activity reached medium intensity in England, Ireland, Northern Ireland and Portugal and has been reported as increasing in additional 11 countries. There is currently widespread activity in England in the UK and Portugal and outbreaks are reported in France and Spain. Most of the influenza virus detections so far have been type A viruses of which the majority were A(H3) viruses. Given the current epidemiological and virological situation it is anticipated that in the coming weeks seasonal epidemic levels of influenza activity will be reached in a number of European countries
Epidemiological situation - week 50/2008: For the intensity indicator, the national network levels of influenza-like illness (ILI) and/or acute respiratory infection (ARI) were medium in Ireland, Portugal and in two of the four parts of the UK (England and Northern Ireland), and low in the remaining 24 countries providing data. Increasing clinical activity, but below baseline levels, was reported in additional 11 countries (Denmark, Italy, Hungary, Lithuania, Poland, Romania, Spain, Slovakia, Slovenia, Sweden and Switzerland). For the geographical spread indicator, widespread influenza activity was reported in the largest part of the UK (England) and in Portugal, while regional activity was reported in another part of the UK (Northern Ireland) and local activity in Spain and France. Sporadic activity was reported in 11 countries (Belgium, Denmark, Germany, Hungary, Ireland, Italy, Luxembourg, Norway, Slovenia, Sweden and Switzerland) while no activity was reported in the remaining 12 countries. Definitions for the epidemiological indicators can be found here.
Cumulative epidemiological situation – 2008-2009 season (weeks 40-50/2008): The consultation rates for ILI and/or ARI are at levels usually seen outside the winter period (i.e. below the national baseline threshold) in the majority of EU countries. However from week 50/2008 medium intensity has been reported in Ireland, Portugal and most of the UK with Portugal and the largest part of the UK (England) also reporting widespread activity. In addition, consultation rates have been reported as increasing in an additional 11 countries.
Virological situation - week 50/2008: The total number of respiratory specimens collected by sentinel physicians in week 50/2008 was 757, of which 196 (25.9%) were positive for influenza virus: 186 type A (135 subtype H3, six H1 and 45 not subtyped) and ten type B. In addition, 159 non-sentinel source specimens (e.g. specimens collected for diagnostic purposes in hospitals) were reported positive for influenza virus: 155 type A (15 subtype H3, one subtype H1 and 139 not subtyped) and four type B. Overall, detection of influenza viruses was reported from 15 countries across Europe.
Cumulative virological situation – 2008-2009 season (weeks 40-50/2008): Of 1087 virus detections (sentinel and non-sentinel) since week 40/2008, 1022 were type A (516 subtype H3, 34 subtype H1 and 472 not subtyped) and 65 were type B.
Based on the antigenic and/or genetic characterisation of 129 influenza viruses, 122 were reported as A/Brisbane/10/2007 (H3N2)-like, three as A/Brisbane/59/2007 (H1N1)-like, two as B/Malaysia/2506/2004-like (B/Victoria/2/87 lineage) and two as B/Florida/4/2006-like (B/Yamagata/16/88 lineage) (click here).
No antiviral resistance against neuraminidase inhibitors was detected in the 27 A(H3N2) virus isolates tested so far this season. Of the 26 A(H3N2) isolates that were also tested for adamantanes susceptibility, all were resistant. In addition, out of the 20 A(H1N1) virus isolates tested for resistance against neuraminidase inhibitors, 19 were oseltamivir-resistant, but all were sensitive to zanamivir and only 1 of 11 tested was resistant to adamantanes. The one type B isolate tested was sensitive to both oseltamivir and zanamivir.
Comment: This week for the first time this season three countries reported levels of influenza activity above their national baseline levels and in two of them a widespread geographical spread was also reported. Despite the remaining countries are still reporting low clinical influenza activity, 11 of them reported increasing activity in week 50/2008 compared to week 49. The current epidemiological situation suggests that in the coming weeks clinical influenza activity may reach seasonal epidemic levels in a substantial number of EU countries. The overall number of sentinel specimens collected for virological testing increased sharply during week 50/2008 compared to week 49/2008 as did the proportion of sentinel specimens which tested positive for influenza virus (from 19% in week49 to 26% in week 50). So far this season, the majority (94%) of viruses subtyped were A(H3). This observation consolidates the earlier indication that the 2008-9 influenza season at this early stage is dominated by A(H3) viruses.
Background: The Weekly Electronic Bulletin presents and comments on influenza activity in the 30 European countries that are members of EISS. Of these countries, 29 reported clinical data and 26 reported both virological and clinical data to EISS in week 50/2008. 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).
Map
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
Only one A/H3N2 influenza isolate has been reported during this week. Three further A/H3N2 viruses have been isolated from samples collected in week 49. Switzerland
Sporadic influenza activity in Switzerland
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.
>>out of the 20 A(H1N1) virus isolates tested for resistance against neuraminidase inhibitors, 19 were oseltamivir-resistant, but all were sensitive to zanamivir and only 1 of 11 tested was resistant to adamantanes. <<
The above suggest that the only H1N1 that was not Tamiflu resistant was clade IIC (which would be Tamiflu sensitive but adamantine resistant).
2008-2009 Influenza Season Week 50 ending December 13, 2008 (All data are preliminary and may change as more reports are received.) Synopsis:
During week 50 (December 7-13, 2008), a low level of influenza activity was reported in the United States.
One hundred three (3.5%) 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.
One pediatric influenza-associated death was reported.
The proportion of outpatient visits for influenza-like illness (ILI) was below the national baseline. The Mountain region reported ILI above their region-specific baseline.
Three states reported local influenza activity; the District of Columbia, Puerto Rico and 36 states reported sporadic influenza activity; and 11 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
3.5 %
0 of 51
196
21
289
132
1
New England
Normal
0.7 %
0 of 6
0
1
8
1
0
Mid-Atlantic
Normal
1.1 %
0 of 3
11
0
4
3
0
East North Central
Normal
6.5 %
0 of 5
12
2
4
6
0
West North Central
Normal
0.4 %
0 of 7
4
0
7
5
0
South Atlantic
Normal
2.2 %
0 of 9
9
0
75
47
1
East South Central
Normal
0.4 %
0 of 4
0
0
0
1
0
West South Central
Normal
4.9 %
0 of 4
32
0
107
52
0
Mountain
Normal
3.3 %
0 of 8
6
12
22
6
0
Pacific
Normal
3.8 %
0 of 5
122
6
62
11
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. Results of these tests performed during the current week and cumulative totals for the season are summarized in the table below.
Week 50
Cumulative for the Season
No. of specimens tested
2,949
36,361
No. of positive specimens (%)
103 (3.5%)
638 (1.8%)
Positive specimens by type/subtype
Influenza A
79 (76.7%)
506 (79.3%)
A (H1)
28 (35.4%)
196 (38.7%)
A (H3)
3 (3.8%)
21 (4.2%)
A (unsubtyped)
48 (60.8%)
289 (57.1%)
Influenza B
24 (23.3%)
132 (20.7%)
Thirty-five states from all nine surveillance regions have reported laboratory-confirmed influenza this season with three states accounting for 483 (75.7%) of the 638 reported influenza viruses.
CDC has antigenically characterized 69 influenza viruses [49 influenza A (H1), seven influenza A (H3) and 13 influenza B viruses] collected by U.S. laboratories since October 1, 2008.
All influenza A (H1) viruses were characterized as A/Brisbane/59/2007-like, the influenza A (H1N1) component included in the 2008-09 influenza vaccine, and five of the seven influenza A (H3) viruses were characterized as A/Brisbane/10/2007-like, the influenza A (H3N2) components included in the 2008-09 influenza vaccine.
Influenza B viruses currently circulating can be divided into two antigenically distinct lineages represented by the B/Yamagata/16/88 and B/Victoria/02/87 viruses. Four influenza B viruses were characterized as B/Florida/04/2006-like, belonging to the B/Yamagata lineage, the influenza B component of the 2008-09 influenza vaccine. The remaining nine viruses belong to the B/Victoria lineage. Eight of the nine viruses belonging to the B/Victoria lineage were from one state.
Data on antigenic characterization should be interpreted with caution given that:
Few U.S. isolates are available for testing because of limited influenza activity thus far.
The majority of viruses antigenically characterized to date come from only two states and may not be nationally representative.
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 which are most similar to the vaccine strains, but can also provide at least partial protection against strains that are related, but antigenically distinct from vaccine strains. 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, 50 influenza A (H1N1), eight influenza A (H3N2), and 20 influenza B viruses from 15 states have been tested for resistance to the two groups of influenza antiviral drugs: neuraminidase inhibitors (oseltamivir and zanamivir) and the adamantanes (amantadine and rimantadine); however, 55% of the viruses tested were from only two states. 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)
50
49 (98%)
0 (0)
50
0 (0%)
Influenza A (H3N2)
8
0 (0)
0 (0)
8
8 (100%)
Influenza B
20
0 (0)
0 (0)
N/A*
N/A*
*The adamantanes are not effective against influenza B viruses.
With low levels of influenza activity thus far in the 2008-09 season in the United States, overall numbers of virus specimens and the number of states that have submitted specimens for testing is limited. The limited data on antiviral resistance, as well as the uncertainty regarding which influenza virus types or subtypes will predominate during the season, make it too early to make an accurate determination of the prevalence of influenza viruses resistant to oseltamivir or the adamantanes (amantadine and rimantadine) nationally or regionally at this time. CDC has solicited a representative sample of viruses from WHO collaborating laboratories in the United States, and more specimens are expected as influenza activity increases. Pneumonia and Influenza (P&I) Mortality Surveillance
During week 50, 6.8% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage is below the epidemic threshold of 7.3% for week 50.
One influenza-associated pediatric death was reported to CDC from Florida during week 50. This death occurred during week 49 (the week ending December 6, 2008). This was the first reported influenza-associated pediatric death 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 – December 6, 2008, preliminary laboratory-confirmed influenza-associated hospitalization rates reported by the EIP for children aged 0-4 years and 5-17 years were 0.24 per 10,000 and 0.01 per 10,000, respectively. For adults aged 18-49 years, 50-64 years, and = 65 years, the rates were 0.02 per 10,000, 0.03 per 10,000, and 0.09 per 10,000, respectively.
During week 50, 1.3% 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 0.4% to 2.2%. One region (Mountain) reported 1.6% of outpatient visits for ILI, which is above their region-specific baseline of 1.5%, while the remaining eight regions reported percentages of visits for ILI below region-specific baseline levels.
During week 50 the following influenza activity was reported:
Local influenza activity was reported by three states (Hawaii, Texas, and Virginia).
Sporadic activity was reported in the District of Columbia, Puerto Rico, and 36 states (Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Utah, Vermont, Washington, and Wisconsin).
No influenza activity was reported in 11 states (Alabama, Kentucky, Louisiana, Nevada, New Mexico, North Carolina, Ohio, Oklahoma, Tennessee, West Virginia, and Wyoming).
--------------------------------------------------------------------------------
A description of surveillance methods is available at: http://www.cdc.gov/flu/weekly/fluactivity.htm
Overall influenza activity in Canada remains low; localized activity reported in a region in British Columbia
During week 50, influenza activity in Canada remained low overall with the majority of the influenza surveillance regions still reporting no activity. Fifteen regions (in BC, AB, ON & QC ) reported sporadic influenza activity and one region in BC (Fraser) reported localized activity this week (see map). Thirty specimens tested positive for influenza in Canada this week (percentage positive = 1.8%; 30/1,671) (see table). The majority of influenza virus detections to date this season were influenza A viruses (59% or 71/120). In week 50, the ILI consultation rate was 16 ILI consultations per 1,000 patient visits (see ILI graph), and is below the expected range for this week. The sentinel response rate was 61%. One outbreak of influenza was reported in a school in BC this week.
Antigenic Characterization:
Since 1 September 2008, the NML has antigenically characterized 16 influenza viruses: 1 influenza A/Brisbane/59/2007(H1N1)-like (from NS), 2 influenza A/Brisbane/10/2007(H3N2)-like (from BC & ON), 3 influenza B/Florida/4/2006-like (from ON and AB) and 10 B/Malaysia/2506/2004-like (from ON and 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 8 influenza A isolates (3 H1N1 and 5 H3N2) for amantadine resistance. All of the H1N1 isolates were susceptible; however all of the H3N2 isolates were resistant to amantadine (resistance = 100% or 5/5). The resistant isolates were from ON, AB and BC.
The NML has also tested 16 influenza isolates (3 A/H1N1, 2 A/H3N2 & 11 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 3/3). The resistant isolates were from NS and BC.
All 12 influenza isolates (1 A/H1N1, 2 A/H3N2 & 9 B) tested for zanamivir resistance to date were sensitive to zanamivir. Oseltamivir resistance findings from Provincial laboratories:
To date this season, 19 influenza isolates in BC have been sub-typed as A/H1 and were assessed genotypically for oseltamivir resistance using an SNP assay. Fourteen isolates tested positive for the H274Y mutation, while the other 5 were indeterminate. These specimens were from community-based cases of ILI; none were associated with an outbreak. 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:
WHO: During the weeks 47 to 48, the level of overall influenza activity in the world remained low with sporadic activity observed in some countries.
CDC: During week 49, a low level of influenza activity was reported in the United States. Three states reported local influenza activity however the majority reported either no activity or sporadic activity. Of the 2,585 specimens tested this week for influenza viruses, 72 (2.8%) were positive. Since 1 October 2008, the CDC has antigenically characterized 36 influenza viruses: 20 influenza A(H1) (all A/Brisbane/59/2007-like), 3 A(H3) (all A/Brisbane/10/2007-like) and 13 influenza B (4 were B/Florida/04/2006-like belonging to the B/Yamagata lineage and the other 9 belonged to the B/Victoria lineage). Since 1 October, 2008, 68 influenza viruses (46 A(H1N1), 7 A (H3N2), and 15 B) have been tested for resistance to neuraminidase inhibitors. Of the A(H1N1) viruses tested, 98% (45/46) 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 30 influenza A viruses (25 H1, 5 H3) for amantadine resistance: all of the H1N1 viruses were sensitive to amantadine however all the H3N2 viruses were resistant.
EISS: In week 50, influenza activity reached medium intensity in several European countries and has been reported as increasing in several others. There is currently widespread activity in England (UK) and Portugal and outbreaks were reported in France and Spain. Most of the influenza virus detections so far have been for influenza A viruses of which the majority were A(H3). Of the 26 A(H3N2) isolates that were also tested for adamantanes susceptibility, all were resistant. Of the 20 A(H1N1) virus isolates tested for resistance against neuraminidase inhibitors, 19 were resistant to oseltamivir (resistance=95%), but all were sensitive to zanamivir.
Human Avian Influenza: Since 12 December 2008, the WHO has reported two new cases of human H5N1 avian influenza infection. The first case was a 19-year-old male from Kendal Province, Cambodia who developed symptoms on 28 November and is currently hospitalized. The second case was a 16-year-old female from Assuit Governorate, Egypt who developed symptoms on 8 December, was hospitalized on 11 December and died on 15 December.
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:
December 7, 2008 to December 13, 2008
Season to Date:
August 24, 2008 to December 13, 2008
Total #
Influenza
Tests
# of Positive Tests
Total #
Influenza
Tests
# of Positive Tests
Influenza A
Influenza B
Total
Influenza A
Influenza B
Total
NL
21
0
0
0
124
0
0
0
PE
0
0
0
0
38
0
0
0
NS
21
0
0
0
210
1
0
1
NB
27
0
0
0
148
0
0
0
QC
590
3
0
3
5077
34
2
36
ON
254
0
2
2
6134
6
5
11
MB
52
0
0
0
711
0
0
0
SK
111
0
0
0
1118
0
0
0
AB
550
5
12
17
6315
9
41
50
BC
45
8
0
8
498
21
1
22
Canada
1671
16
14
30
20373
71
49
120
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,
December 7, 2008 to December 13, 2008 (Week 50)
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=16]
{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 2006/07 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
however all of the A/H1N1 isolates were resistant to oseltamivir due to the H274Y mutation (resistance = 100% or 3/3). The resistant isolates were from NS and BC.
H1N1 Tamiflu Resistance at 100% in Canada Recombinomics Commentary 01:07
December 20, 2008
however all of the A/H1N1 isolates were resistant to oseltamivir due to the H274Y mutation (resistance = 100% or 3/3). The resistant isolates were from NS and BC.
The above comments from the week 50 influenza report from Canada indicate H1N1 oseltamivir resistance in Canada is currently at 100%. Although only three isolates have been tested, it is a marked improvement over the one tested at the beginning of the season. The isolates are from the opposite ends of Canada, and match the results in the United States, where 49/50 H1N1 isolates have H274Y.
The United States has issued an advisory to physicians, describing the high levels of resistance in seasonal flu, since the vast majority of flu in the US currently is influenza A and the vast majority of influenza A is H1N1.
The resistance levels in H1N1 in Europe are also near 100% in England, at at 100% in Scotland, Norway, and Austria, although the number of samples tested remain low. However, in Europe most of the influenza A is H3N2, which is sensitive, so an advisory in Europe has not been issued to physicians, although England did put out a report on the high frequency in H1N1.
The levels of resistance in North America and Europe suggest that the resistance levels in H1N1 are not likely to change this season.
.
__________________
"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
A flu type virus has led to a surge in telephone calls to GPs and emergency services across the region.
Medical staff at doctors surgeries across Solihull have witnessed a rocketing number of enquiries, averaging 20 to30 per day relating to the virus which causes a cold and chest pains among all ages during the past week.
In addition, West Midlands Ambulance Service based in Dudley, took an estimated 2,146 calls during last Saturday (December 13) alone, representing a 30 per cent increase for the same period last year.
Dr Patrick Brooke, medical director for Solihull NHs Care Trust in Union Road, is urging people with colds and flu-like symptoms to seek the right treatment for their illness and not to use the Accident and Emergency departments of Solihull Hospital.
“There has been a tremendous health service response to this unprecedented demand,” he said. “GPs and community services staff have made a concerted effort to deal with the high level of demand and help to relieve the pressure on local hospitals.
“One of the main problems recently is a flu-like illness, the Norovirus which causes respiratory problems, sickness and diarrhoea. This has hit old people particularly hard. While NHS staff are always there to help, there is a lot people can do for themselves and their families to avoid becoming ill or having accidents.”
Any members of the public with flu-like symptoms are advised to take plenty of rest, consume hot drinks and plenty of fluid, wear extra layers of warm clothing, stay at home, wash their hands regularly and use their local GP or pharmacy for treatment and advice.
Britain gripped by worst flu outbreak since 2000
Britain is in the grip of the worst flu outbreak for eight years, with emergency services fearing they will be "swamped" by calls when GP surgeries close for Christmas.
By Laura Donnelly, Health Correspondent
Last Updated: 4:20PM GMT 20 Dec 2008
This week’s official flu figures are expected to show a further surge in the number of people infected.
With most GPs surgeries shut for four days over the Christmas period, experts said the remaining medical services would become stretched to breaking point by the weekend.
Accident and Emergency doctors said the chaos in their departments was already reminiscent of scenes from the last big NHS winter crisis, at the turn of the millenium, when crematoriums were forced to work around the clock to cope with the 22,000 people who died.
The latest figures show the number of flu infections running at 40 per 100,000 - the highest level at this point in the year since the winter of 2000-1, when flu rates went on to reach epidemic proportions.
Dozens of hospitals have closed wards or stopped admitting emergency patients as they battle with the rising number of admissions linked to flu and the vomiting bug norovirus. Record numbers of 999 calls have left emergency services struggling to cope, with ambulances queuing outside hospitals who are unable to take patients quickly enough.
John Heyworth, president of the College of Emergency Medicine, said Accident and Emergency departments and ambulance services were already overstretched, with patients facing long waits in ambulances and on trolleys.
“The system simply does not have enough capacity to cope with the pressure it is under, and we expect this to keep getting worse over Christmas, and then over the next three to four weeks,” he said.
The A&E consultant at Southampton General Hospital said: “Already we have got scenes where patients are waiting hours in A&E, or on trolleys in corridors because there are not enough beds to admit them. Outside the hospitals, ambulances are backed up, and can’t unload patients because the departments aren’t able to cope with them.
“The ambulance service and A&E departments are already inundated with patients and we fear we will soon be swamped,” he added.
Mr Heyworth described current pressures as “very reminiscent” of the crisis in the NHS over the millenium.
“What is really frustrating about this, is that these pressures are predictable,” he said. “The reason the service struggles to cope is because bed numbers have been cut to a minimum”.
After the 1999/2000 winter crisis, the Government pledged to increase the number of hospital beds by 7,000. In fact, the number of beds has fallen by 13,000 since then.
Meanwhile, hospitals are continuing to carry out thousands of operations in a desperate attempt to meet a Government deadline at the end of this month.
The British Medical Association said “inflexible targets” which mean patients must be treated within 18 weeks of referral, by the end of this month, meant hospitals had failed to create enough slack in the system to cope with the growing crisis.
Jim Wardrope, an A&E consultant at Sheffield Northern General Hospital, said: “We are currently at a stage where we have severe and sustined pressures and we are really worried about the four day weekend around Christmas. Some places will run some extra services out of hours, but the reality is we do not have a national plan to deal with this.”
The national director for the ambulance service has already begged the public not to call 999 or visit A&E unless they have a genuine emergency, urging people to call NHS Direct, visit their pharmacy or try a walk-in centre if they need advice.
Ambulance staff said changes to the running of GP services, which mean most surgeries no longer responded to calls in the evenings and weekends, with the work “outsourced” to private companies, had left the public confused about who to contact if they needed to see a doctor when their local surgery was shut.
Sam Oestreicher, UNISON National Officer for Ambulance workers, said: “The four day weekend is a real concern; a lot of people don’t know how to access care when their GP surgery is shut, but the one number they do know is 999, so it is very hard to keep the pressure off the ambulances”.
On Thursday the health secretary Alan Johnson insisted that the increase in sickness was “pressure we can cope with.”
He was responding to comments from Peter Bradley, the national director of ambulance services, who told The Daily Telegraph that the emergency system was “struggling to cope” with demand.
Latest figures show that the London Ambulance Service, where he is chief executive, experienced its busiest week in its history, with more than 20,000 calls in the week ending last Sunday, while calls in the West Midlands rose by 30 per cent, compared with the same period last year.
St George’s Hospital in London, Leighton Hospital in Cheshire, and Norfolk and Norwich Hospital have all stopped receiving emergency patients as pressures mounted over the past fortnight, due to rising emergencies and outbreaks of the vomiting bug.
Dozens more hospitals have closed wards and cancelled scheduled operations
Red Cross to answer 999 calls in winter flu crisis as NHS is deluged by emergencies
By Lucy Ballinger
Last updated at 1:14 AM on 22nd December 2008
Volunteers from the Red Cross and St John Ambulance are being sent to 999 calls as the ambulance service is hit by a deluge of emergencies.
Crews are faced with the worst flu outbreak for ten years, the winter vomiting bug and a wave of alcohol-related injuries from the Christmas party season.
In desperation they have turned to the charities to help them with the massive influx of calls.
The Red Cross, more usually linked to disasters in the Third World, has been called in to help with non-life-threatening calls.
And St John Ambulance, which deals with any call-up to the most serious kind, says it is being forced to provide three times the cover it normally does at this time of year.
Even firemen in some areas are poised to give emergency assistance while patients wait for ambulances to arrive.
Peter Bradley, the national director of ambulance services, said services in England the week before last was their busiest ever, with a 30 per cent rise in some areas during the ten days up to the middle of last week.
He said it was due to the coldest start to a winter for 30 years causing a sharp increase in falls and breathing problems, combined with outbreaks of flu and the winter vomiting bug norovirus.
'It is absolutely horrendous. Hospitals are full and A&E departments are struggling,' he said.
St John Ambulance chief commissioner of operations Harry Dymond said: 'We are probably operating in every county in England. If not every one, then certainly the vast majority. Huge numbers of vehicles are helping, with up to ten being used in many counties.
'Most of the crews will be dealing with emergency calls in the same way as any other normal ambulance crew. This can mean going to any type of call including the most serious heart attacks.
'We expect to have to help out well into next year. In many areas we have already been asked to help through to the middle of January.'
He added that this year ambulance services were under extra pressure to meet new Government response time targets set this spring.
Last Friday over-indulgence at office celebrations saw London Ambulance service receive 4,549 calls, which they said was 'extremely busy' compared with a normal day's average of 3,500 calls.
Geoff Martin from Health Emergency, which represents paramedics, said: 'We have got a combination of flu and norovirus and cold weather, and it has led to absolute chaos.
'The services are trying to muddle through and that is the problem. The problem has been compounded by the target-obsessed Government.
'To use these volunteer organisations is a measure of how desperate the situation is. We have the emergency services for a reason. There is no substitute for those trained professionals, it is not their fault but this is a dire situation.'
The Red Cross has 300 ambulances across Britain who are on stand-by all year for emergencies, but are very rarely needed.
A Red Cross spokesman said: 'We provide support to the emergency services as needed, this includes helping some ambulance services with lower category calls.
'All our ambulances are fully equipped, and the crews are fully trained.'
Neil Cook, director of operations for the east Hampshire ambulance area, said: 'I've been in this job for 25 years and I can't remember it ever being this bad.
'The increase in call outs is putting us under incredible strain.'
Ambulance service managers are urging patients to think carefully before dialling 999 - as they could be diverting an ambulance from a life-threatening emergency.
Michelle Ullett, from South Central Ambulance Service, which covers Hampshire, said: 'In some cases people don't know where else to turn and think dialling 999 is their only alternative.
'There are a lot of people who do not need an ambulance but may need some other form of NHS treatment from places such as their GP, NHS Direct, minor injuries or walk-in centres or out-of-hours service.'
"Ambulance service managers are urging patients to think carefully before dialling 999 - as they could be diverting an ambulance from a life-threatening emergency."
The above is a product of an "one-number-for-all-emergencies", which is not bad if covered with enaugh real-time specialistics phone-call "judge it" staff and enaugh inner channels, and emergency vehicles/dr/staff,
but if not,
the outcome can be dificultly and serious for the people who need realy an express life-save ambulance without the need for other kind of specialists but doctors (heart, ...),
if they can't get the vehicle/dr./staff/em.treatment because the lines are occupated by un-neccessary urgent calls evaluations or team interventions.
Two diferent main call numbers - one for the suspected vital urgent emergency calls only,
and another for the rest of potential emergencies?
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Re: Seasonal Flu 2008 - 2009
News Editor
Linear Mode
