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2009 swine flu pandemic

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Template:WebSlice-begin Template:2009 swine flu outbreak table Template:WebSlice-end The 2009 swine flu outbreak is the spread of a new strain of H1N1 influenza virus that was first detected by public health agencies in March 2009.[1] Local outbreaks of influenza-like illness were first detected in three areas of Mexico, but the new strain was not clinically ascertained as such until a month later in cases in Texas and California, whereupon its presence was swiftly confirmed in various Mexican states and Mexico City; within days isolated cases elsewhere in Mexico, the U.S., and the Northern Hemisphere were also identified. By April 27, the new strain was confirmed in Canada, Spain, and the United Kingdom and suspected in many other nations, including New Zealand, with over 2,400 candidate cases, prompting the World Health Organization (WHO) to raise their pandemic alert level to 4.[2][3] A level 4 warning officially means that the WHO considers that there is "sustained human to human transmission"; whereas levels 5 and 6 represent "widespread human infection"[4].

The new strain is an apparent reassortment of several strains of influenza A virus subtype H1N1, including a strain endemic in humans and two strains endemic in pigs, as well as an avian influenza.[5]

In April both the WHO and the United States Centers for Disease Control and Prevention (CDC) expressed serious concerns about the situation. It had the potential to become a flu pandemic because the strain was novel, transmitted from human to human against little immunity, and the Mexican mortality rate was unusually high.[6] On April 25, 2009, the WHO determined the situation to be a formal "public health emergency of international concern", with knowledge lacking in regard to "the clinical features, epidemiology, and virology of reported cases and the appropriate responses".[7] Government health agencies around the world also expressed concerns over the outbreak and are monitoring the situation closely.

As of April 26, 2009, Mexico City schools, universities, and all public events remained closed or suspended[8] while other schools in the U.S. closed due to confirmed cases in students.[9][10] On April 27, 2009, Mexican government officials announced a nationwide shut down of schools.[11][12][13]

Prior influenza season

Prior to the outbreak, the Northern Hemisphere winter of 2008–2009 had been a comparatively mild season for flu infections, which typically cause 250,000–500,000 deaths worldwide yearly, mostly in the elderly, the very young, and persons with chronic illness.[14] Up to April 8, 2009, the CDC had reported the deaths of 43 children from seasonal flu, compared to 68 in the previous flu season.[15] The improvement was attributed in part to an improved Northern Hemisphere winter of 2008–2009 seasonal flu vaccine, for which a rare decision had been made to update all three strains (H1, H3, and B) simultaneously, which ultimately yielded a very good match to the strains of H1N1 and H3N2 which eventually circulated. (This followed the poor performance of the 2007–2008 vaccine, which offered only 2–20% protection rather than the 70–90% achieved in some years.) The improvement was also attributed to new recommendations including the vaccination of people 5–18 years of age, who potentially act as "super-spreaders" due to failure to take precautions such as hand-washing.[16][17]

Furthermore, from December 2005 through February 2009, a total of twelve human infections with swine influenza were reported from ten states in the USA.[18]

Initial outbreak

  Confirmed cases followed by death
  Confirmed cases
  Unconfirmed or suspected cases
See also: Live map of swineflu, H1N1 live map
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The earliest known case was at a Mexican pig farm whose nearby neighbors had been complaining about the smell and flies.[19] The outbreak was first detected in Mexico City, where surveillance began picking up a surge in cases of Influenza like illness (ILI) starting March 18.[20] The surge was assumed by Mexican authorities to be "late-season flu" (which usually coincides with a mild Influenzavirus B peak[21]) until April 21,[22][23] when a U.S. Centers for Disease Control and Prevention alert concerning two isolated cases of a novel swine flu was reported in the media.[24] The first two cases identified (and confirmed) as swine flu were two children living in the United States, in San Diego County and Imperial County, California, who became ill on March 28 and 30.[25] This new strain was promptly confirmed in Mexico, connecting the new strain to the ongoing outbreak of ILI. The first deadly case seems to go back to April 13, where it is believed that the first case was in a woman from Oaxaca.[26] Some samples were sent to the U.S.-based CDC on April 18.[27] News of the connection was broadcast live in Mexico on April 23, 2009.

In March and April 2009, over 1000 cases of suspected swine flu in humans were detected in Mexico and the southwestern United States. The strain appears to be unusually lethal in Mexico, causing 152 deaths (20 confirmed)[28] so far, mostly in Mexico City.[29] There have also been cases reported in the states of San Luis Potosí, Hidalgo, Querétaro and Mexico State, all in central Mexico;[30] Some cases in Mexico and the United States have been confirmed by the World Health Organization to be a never-before-seen strain of H1N1.[20][31] The Mexican fatalities are mainly young adults of 25 to 45, a hallmark of pandemic flu.[5][32] A new swine flu strain was confirmed in 16 of the deaths and at least 100 others were being tested as of April 24, 2009.[33] Mexican Health Minister José Ángel Córdova on April 24, said "We’re dealing with a new flu virus that constitutes a respiratory epidemic that so far is controllable."[30]

The origins of the new virus strain remain unknown. One theory is that Asian and European strains traveled to Mexico in migratory birds or in people, then combined with North American strains in Mexican pig factory farms before jumping over to farm workers.[34] The Mexican health agency acknowledged that the original disease vector of the virus may have been flies multiplying in manure lagoons of pig farms near Perote, Veracruz, owned by Granjas Carroll,[35] a subsidiary of Smithfield Foods.[36] Smithfield Foods responded, saying that that it had found no clinical signs or symptoms of the presence of swine influenza in the company's swine herd, nor in its employees at its joint ventures in Mexico, and that it routinely administers influenza virus vaccination to their swine herds and conducts monthly testing for the presence of swine influenza.[37]

Genetics and effects

Influenza (flu)
H1N1 virus
Types
Vaccines
Treatment
Pandemics
Outbreaks
See also

The CDC has confirmed that American cases were found to be made up of genetic elements from four different flu viruses – North American swine influenza, North American avian influenza, human influenza, and swine influenza virus typically found in Asia and Europe – "an unusually mongrelised mix of genetic sequences."[38] Pigs have been shown to act as a potential "mixing vessel" in which reassortment can occur between flu viruses of several species.[39][40] This new strain appears to be a result of reassortment of human influenza and swine influenza viruses, presumably due to superinfection in an individual human. Influenza viruses readily undergo reassortment because their genome is split between eight pieces of RNA (see Orthomyxoviridae).

The virus was resistant to amantadine and rimantadine, but susceptible to oseltamivir (Tamiflu) and zanamivir (Relenza).[41][42][43][44]

Several complete genome sequences for U.S. flu cases were rapidly made available through the Global Initiative on Sharing Avian Influenza Data (GISAID).[45][46] Preliminary genetic characterization found that the hemagglutinin (HA) gene was similar to that of swine flu viruses present in U.S. pigs since 1999, but the neuraminidase (NA) and matrix protein (M) genes resembled versions present in European swine flu isolates. The six genes from American swine flu are themselves mixtures of swine flu, bird flu, and human flu viruses.[47][48] While viruses with this genetic makeup had not previously been found to be circulating in humans or pigs, there is no formal national surveillance system to determine what viruses are circulating in pigs in the U.S.[49] The seasonal influenza strain H1N1 vaccine is thought to be unlikely to provide protection.[50]

Main symptoms of swine flu in humans.[51]

The CDC does not understand why the American cases were primarily mild disease while the Mexican cases had led to multiple deaths. However, research on previous pandemic strains have suggested that mortality can vary widely between different countries, with mortality being concentrated in the developing world.[52] Differences in the viruses or co-infection are also being considered as possible causes. Only fourteen samples from Mexico had been tested by the CDC, with seven found to match the American strain. The virus likely passes through several cycles of infection with no known linkages between patients in Texas and California, and that containment of the virus is "not very likely".[53][54] The U.S. embassy reported that a CDC investigative team arrived in Mexico City on April 25 to work with Mexican counterparts to study the virus.[22] While the seasonal flu kills less than 1% of those infected, the Mexican fatality rate represents a 7% rate. This compares to the global rate of more than 2.5% for the Spanish flu pandemic of 1918.[55]

At a press briefing on April 27, acting CDC director Dr. Richard Besser stated that out of 40 confirmed cases in the United States at that point, only one individual was hospitalized. He also revealed that the median age was 16 years "with a range in age of 7 to 54 years."[56]

Pandemic concern

See also: Pandemic Severity Index

The U.S. Centers for Disease Control (CDC) and the World Health Organization (WHO) are concerned that this outbreak may become a pandemic, for the following reasons.[57]

New strain
The virus is a new strain of influenza, from which human populations have not been vaccinated or naturally immunized.[58]
Widespread human transmission
The virus appeared to infect by human-to-human transmission. Investigations of infected patients indicated no direct contact with swine, such as at a farm or agricultural fair.[31] The strain was later confirmed to have been transmitted between humans.[59] In contrast, for example, disease transmission in the last severe human outbreak of influenza, the bird flu that peaked in 2006, was determined to be almost entirely from direct contact between humans and birds.[60]
Virulence
The virus has produced severe disease in Mexico, and some deaths. Furthermore, in Mexico (but not in the United States) the illness has primarily struck young, healthy adults, much like the deadly Spanish Flu of 1918, possibly because of the phenomenon known as cytokine storm.[61] Most other influenza strains produce the worst symptoms in young children, elderly adults, and others with weaker immune systems.[31][62]
Lack of data
That other factors are still somewhat unknown, such as transmission rates and patterns and effectiveness of current influenza treatments, combined with the unpredictability of influenza strains, means that reliable forecasts cannot be made.[7]

As noted, predicting the size and severity of influenza outbreaks is a very inexact science. The U.S. government was famously wrong in predicting, in 1976, a swine flu pandemic that never materialized.[63]

Prevention and treatment

Train commuters in Mexico City wearing surgical masks.

Recommendations to prevent infection by the virus consist of the standard personal precautions against influenza. This includes frequent washing of hands with soap and water or with alcohol-based hand sanitizers, especially after being out in public. People should avoid touching their mouth, nose or eyes with their hands unless they've washed their hands. If people do cough, they should either cough into a tissue and throw it in the garbage immediately or, if they cough in their hand, they should wash their hands immediately.[64]

Many countries confirmed that inbound international passengers will be screened. Typical airport health screening involves asking passengers which countries they have visited and checking whether they feel or look particularly unwell. Thermographic equipment was put into use at a number of airports to screen passengers. In the USA, two confirmed cases were detected through their border infectious disease surveillance.[65] A number of countries advised against travel to known affected regions.

The previously recommended influenza vaccines for the southern and northern hemispheres, including that for the 2009/2010 flu season, are ineffective against the new strain.[66] Current development, large-scale manufacturing, distribution and delivery of a new vaccine takes several months.[65] The WHO Director-General announced that production of the unchanged seasonal vaccine should continue for now, and that the WHO would assist the development process for an effective vaccine.[67]

U.S.-based medical product company Baxter International has requested a virus sample from the WHO in order to begin development of a new vaccine.[68] Baxter has patented a cell-based technology that may allow the company to develop a vaccine in half the time it usually takes, possibly cutting development time from six months to three.[69]

Of the available antiviral treatments for influenza, the WHO stated that the viruses obtained from the human cases with swine influenza in the United States were sensitive to oseltamivir (Tamiflu)[70] and zanamivir (Relenza) but resistant to amantadine and remantadine.[71] Tamiflu and Relenza also have a preventative effect against Influenzavirus A.[72]

On April 27, the CDC recommended the use of Tamiflu and Relenza for both treatment and prevention of the new strain.[73]

Roche and the US government had already extended the shelf-life of federally stock-piled Tamiflu from the original five years to seven years because studies indicated that the medication continues to maintain its effectiveness.[74]

Some physicians in the US are recommending the use of masks when in public.[75] The purpose of a face mask is to effectively cover a person's mouth and nose so that if a person is around someone who is infected, there is a decreased likelihood of transmission. Recommendations to protect against the avian flu indicated that using a face mask with a rating of N99, N100 or P100 in the United States or a rating of FFP3 in Europe should be effective in protecting against transmission.[76] While face masks with these ratings provide 99% or greater efficiency in protecting against flu transmission, N95 or FFP2 face masks provide about 94% efficiency.[77] N95 and FFP2 rated face masks may therefore also be effective.

However, in the United Kingdom, Health Secretary Alan Johnson told MPs on April 27 that, "Although we are aware that facemasks are being given out to the public in Mexico, the available scientific evidence does not support the general wearing of facemasks by those who are not ill, whilst going about their normal activities."[78]

On April 28, the WHO flu expert Keiji Fukuda pointed out that it is too late to contain the swine flu.[79] "Containment is not a feasible operation. Countries should now focus on mitigating the effect of the virus," he said.[79] He also stressed that the experts did not recommened closing borders or restricting travel.[79] "With the virus being widespread... closing borders or restricting travel really has very little effects in stopping the movement of this virus."[79]

UN World Health Organization

Congruent WHO and U.S. Government Pandemic Response Charts

The World Health Organization (WHO) saw no need at this point to issue travel advisories warning travellers not to go to parts of Mexico or the United States. The spokesperson said that the situation might change "depending on what the situation in the field is".[80] WHO Director-General Dr. Margaret Chan also said that it was too premature to issue such recommendations without better analysis and understanding of the situation at this stage.[81]

In a statement, the WHO said "Because there are human cases associated with an animal influenza virus, and because of the geographical spread of multiple community outbreaks, plus the somewhat unusual age groups affected, these events are of high concern" and "WHO acknowledges the United States and Mexico for their proactive reporting and their collaboration with WHO and will continue to work with Member States to further characterize the outbreak".[31]

The WHO established the Emergency Committee of the International Health Regulations for emergency discussions to assess the situation and to formulate appropriate responses, and to provide guidance and advice to the Director-General.[82] The first meeting of the committee was held on April 25 in Geneva.[7]

Before the first meeting, WHO Director-General Margaret Chan said that the Emergency Committee could make recommendations including whether to change the pandemic alert level or not.[80][83]

The Emergency Committee "identified a number of gaps in knowledge about the clinical features, epidemiology, and virology of reported cases and the appropriate responses", and on its advice, the WHO advised "that all countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia".[7]

The WHO decided not to raise the level of the worldwide pandemic alert after the first meeting.[84] A Phase 3 alert means that a new virus has been confirmed but there is no or limited evidence of human-to-human transmission - insufficient to sustain community-level outbreaks. The Phase 3 alert was initially set due to the avian flu.[85][86][87] (Phase 4, "Sustained Human to Human Transmission," entails community-wide outbreaks; Phases 5/6, "Widespread Human Infection," entails human-to-human transmission in at least two countries in one WHO region; Phase 6 is a global pandemic proper.)[88] Following the second meeting of the Emergency Committee on April 27, 2009, the WHO raised the pandemic alert level to 4.[67]

Cases and responses by nation

Asia

China, the People's Republic of

The General Administration of Quality Supervision, Inspection and Quarantine (AQSIQ) of China issued an emergency notice on the evening of 26 April that visitors returning from flu-affected areas who experienced flu-like symptoms within two weeks would be quarantined.[89] The Ministry of Health has started prevention measures, and initiated cooperation with the WHO and the relevant departments of the Mexican and U.S. governments to help contain the outbreak. According to Wang Jing of the China Inspection and Quarantine Science Research Institute, the measures already in place in China against bird flu are sufficient for this new disease.[90]

China, the Republic of (Taiwan)

Although no cases of the influenza have been reported in the Republic of China (Taiwan), the government has already taken several steps to prevent the possible outbreak of Swine Flu, including a command center set up, travel alerts for infected nations[91], and more severe health check been conducted at international ports. According to The Department of Health (DOH), Taiwan has a sufficient supply of surgical masks and vaccine to deal with the flu. The DOH also stated that they have 50 million to 60 million masks in stock and local manufacturers have the capability of producing 200,000 doses of the flu vaccine a month.[91] In an effort to prevent the entry of the swine influenza, the Centers for Disease Control has announced on April 28 that every flight from Americas that arrives in Taiwan from April 29 and onward will be subject to a strict on-board screening procedure.[91]

Hong Kong Special Administrative Region

Hong Kong has said visitors who came back from affected areas with fevers would be quarantined.[91]

India

The Government of India has decided to screen all people entering India via the main airport hubs of Mumbai, New Delhi, Goa, Jaipur, Kochi, Chennai, Bangalore and Hyderabad. It said the primary focus will be on passengers entering from the United States of America, The United Kingdom, Canada, Mexico, France and New Zealand. A team of 32 highly skilled medical professionals have been posted at these airports. The Ministry of Health is also trying to track down people who have entered India from Mexico in the last 10 days.[92]

Indonesia

After a coordination meeting about the flu on April 27, 2009, the Indonesian government halted the importation of pigs and initiated the examination of 9 million pigs in Indonesia.[93] Thermal scanners which can detect human body temperature have been installed at Indonesian ports of entry. Temperatures above 38 degrees Celsius (100.4 Fahrenheit) cause the devices to beep, indicating fever. The devices have been installed in Soekarno-Hatta International Airport and Halim Perdana Kusuma Airport in Jakarta, Juanda Airport in Surabaya, Hang Nadim Airport in Batam, Hasanudin Airport in Makassar, Ngurah Rai Airport in Denpasar, Sepinggan Airport in Balikpapan, and Tanjung Priok Seaport, gates one and two in Jakarta.[94]

Japan

The Ministry of Agriculture, Forestry and Fisheries of Japan instructed animal quarantine offices across Japan to examine any live pigs being brought into Japan to make sure they are not infected with the influenza.[95] Japanese Agriculture Minister Shigeru Ishiba appeared on television to reassure customers that it was safe to eat pork.[91] The Japanese farm ministry said that it would not ask for restrictions on pork imports because the virus was unlikely to turn up in pork, and would be killed by cooking.[96]

Malaysia

According to the Malaysian Health Ministry, health screenings will be carried out on passengers traveling to and from Mexico beginning on April 17.[97] The Health Ministry’s disease control division has activated its operations room to monitor the swine flu situation and informed medical practitioners who are treating cases with symptoms of influenza-like illness or severe pneumonia and persons had visited Mexico, California or Texas, to inform the district health office immediately for preventive and control measures.[98]

Philippines

Philippines' Health Secretary Francisco T. Duque III has ordered the Bureau of Quarantine to use thermal imaging equipment at airports to screen passengers coming from the US for flu symptoms.[99] The Philippines may quarantine travelers arriving from Mexico with fevers.[100] Also, the Secretary of the Department of Agriculture of the Philippines issued an order banning the importation of hogs from the U.S. and Mexico, and the retraction of the restriction of swine influenza vaccine use.[101]

Singapore

Singapore's Minister of Health Khaw Boon Wan has urged citizens to limit travel to affected areas such as Mexico and the United States. The Health Ministry has advised the public to seek immediate medical attention if they experience influenza symptoms within seven days after arriving from affected areas, to maintain good hygiene, and for those who are sick with respiratory illnesses to avoid crowded areas and wear masks.[96]

South Korea

South Korea warned against travel to Mexico City and three Mexican states.[91] The government has also stepped up quarantine and safety checks on travelers arriving from the United States and Mexico, and pork imports from those countries. An emergency quarantine system is also in place, with simple tests conducted on people arriving with flu symptoms at airports.[89] On April 28, South Korea reported its first probable case of swine flu after positive preliminary tests on a woman who had recently returned from a trip to Mexico.[102]

Thailand

The Thai Government has installed thermal scanners in Suvarnabhumi Airport and two other airports. Airport health officials began using thermal screening equipment to monitor passengers arriving from the southern United States and Mexico for flu-like symptoms including fever to prevent spreading swine flu. Each unit comprises an infrared thermal camera, a processor and a monitor to show the results of readings. Travellers found with suspicious flu symptoms that could develop into swine influenza will be asked to undergo treatment at 17 state hospitals. The hospitals are on full flu alert and they will be assisted by the private sector. Medical instruments and drugs are ready to support the operation. On the 28th of April 2009, the Thai Public Health Ministry issued a warning for Thais to avoid visiting the United States and Mexico which have been hit by the Mexican Flu. The Thai cabinet has formed a national emergency committee to oversee prevention operations against the swine flu, Prime Minister Abhisit Vejjajiva said. [103] [104]

Vietnam

Vietnam's Ministry of Health released a emergency dispatch and urged agencies to take precautionary measures against swine flu. In addition, the Preventive Health and Environment Bureau requested all health facilities to carefully monitor any suspected H1N1 case and this Bureau head, Nguyen Huy Nga, also warned the pandemic could enter Vietnam through imported swines or border gates.[105] Thermal imaging devices were dispatched to airports and border gates to screen passengers.[106]

Europe

On April 27, the European Union health commissioner advised Europeans not to travel to the United States or Mexico unless urgent. This followed the first confirmed case being discovered in Spain.[107]

France

Three cases in France are currently under investigation: one in Pau, in Nantes and the last one in Poitiers. Seven other cases have been excluded after analysis.[108]

Germany

Two men and a woman from Bielefeld who had been suspected of having the virus tested negative on influenza type A.[109]

Iceland

Iceland is currently being briefed by the WHO and is cooperating closely with ECDC and the EU in terms of monitoring and response. Iceland has not yet implemented travel restrictions but has warned people traveling to Mexico and The United States (especially California and Texas) to exercise caution and to contact a doctor immediately if they start showing symptoms of swine flu.[110]

On April 28 it was announced that passengers arriving in Iceland from the United States or Mexico would be monitored and will undergo medical examination even if the slightest signs of influenza are detected[111].

Iceland has stocks of Tamiflu and Relenza for 1/3 of its population[112].

In a risk assessment made by the Icelandic government in 2008 in case of a influenza pandemic two scenarios are envisioned:

  • A worst-case scenario where 50% of the Icelandic population are infected and 3% of the infected population die.
  • A milder scenario where precautionary measures prevent infection, 25% of the Icelandic population are infected and 1% die.[113]

Italy

Italy's agriculture lobby, Coldiretti, warned against panic reaction, noting that farmers lost hundreds of millions of euros due to consumer boycotts during the 2001 mad cow scare and the 2005 bird flu outbreak.[114]

Netherlands

The Netherlands National Institute for Public Health and the Environment advised any traveller who returned from Mexico since April 17 and developed a fever of 38.5 degrees Celsius (101.3 degrees Fahrenheit) within four days of arriving in the Netherlands to stay at home.[100]

Norway

As of April 28, three persons have tested negative for swine flu[115]. Test results are not yet in for a two year old boy from Revetal, Vestfold, which has been returning from vacation in Mexico with flu-like symptoms.[116]

The Norwegian government projects that in the worst case, 1.2 million Norwegians may fall ill and 13,000 may die.[117]

Poland

Three cases in Poland are currently under investigation: one in Zielona Góra and two in Wroclaw.[118] The Polish Foreign Ministry issued a statement recommending that citizens avoid travel to affected areas until the outbreak is totally contained.[100]

Russia

Russia has banned the import of pork meat from Guatemala, Honduras, Dominican Republic, Columbia, Costa Rica, Cuba, Nicaragua, Panama, El Salvador, 9 US States (Alabama, Arizona, Arkansas, Georgia, Kansas, Louisiana, New Mexico, Oklahoma and Florida) and all types of meat and meat products from Mexico and 5 US States (California, Texas, Kansas, New York and Ohio).[119][120][121].

The President instructed the regional governors to take urgent steps to prevent swine flu from spreading to Russia. Mr Medvedev also instructed the presidential plenipotentiary envoys in the federal districts to personally supervise the preventive measures to ensure the disease did not spread [in Russia] and stipulated monthly reports on the situation. [122].

Serbia

Serbia, on Saturday, April 25, banned all imports of pork from North America, despite reassurances from the Food and Agriculture Organization (FAO) of United Nations that pigs appear not to be the immediate source of infection.[114]

According to Deputy Health Minister Svetlana Mijatović, Serbia will adhere to all WHO recommendations for monitoring the swine flu epedemic.[123] "A sanitary inspection, together with Serbian Ministry of Internal Affairs (MUP), is checking travelers, [...] while the media and all the agencies throughout the world, as well as our own, are constantly informing the public that if anyone feels ill, or is coming from a contaminated area, to consult the authorities at any airport in the world [...]," Mijatović said.[123]

Flights and holidays to Mexico and the U.S. have yet to be canceled, and the advice to citizens traveling to infected countries is to take precautions in terms of immunity and to maintain personal hygiene.[123]

Spain

Main article: 2009 swine flu outbreak in Spain
  Confirmed cases
  Unconfirmed or suspected cases

On April 27 the Spanish Ministry of Health and Social Policy announced that a man in Castilla-La Mancha who had recently returned from Mexico had contracted the disease. The man, aged 23, had returned from Mexico on April 22 and had been quarantined on the 25th. This was the first confirmed case in Europe.[124]

The Spanish government is also observing other 35 possible swine flu cases in the Basque Country, Catalonia, the Balearic Islands, Andalusia, Murcia, Madrid and the Valencian Community.[125]

AENA, the Spanish state owned company who manages all Spanish airports and Air Traffic Control established a protocol for the flights coming from and to Spain from the affected areas.[126] Three patients who had just returned from Mexico were under observation in multiple regions of Spain.[114]

Sweden

On April 27, at least five Swedish people were tested for swine flu after returning from trips in Mexico and the USA, but the results were negative.[127]

Switzerland

The first suspicious case was officially confirmed on April 27. A young man returning from holiday in Mexico informed his family doctor about fever and flu-like symptoms. He was immediately put under quarantine in a hospital. Four more people are under observation.[128]

United Kingdom

Main article: 2009 swine flu outbreak in the United Kingdom

In the United Kingdom, on April 25, 2009, a member of the cabin crew from British Airways flight number BA242 was taken to Northwick Park Hospital in Harrow and quarantined after falling ill with flu-like symptoms on a flight from Mexico City to Heathrow.[129] On April 26 after undergoing testing, Northwick Park Hospital confirmed the crew member did not have the swine flu.[130]

On April 26, two people were admitted to Monklands Hospital in Scotland with mild flu-like symptoms after returning from Mexico. On 27 April 2009, these cases were confirmed as mild swine flu.[131][132] Four people were given medication and advised to stay in their home in Stanwick, Northamptonshire, again after returning from Mexico with flu-like symptoms.[133] In both cases the symptoms were said to be mild. On the same date, passengers were held on planes arriving at Heathrow, from Mexico City, whilst officials carried out health checks.[134]

A Canadian woman visiting Manchester has been submitted to hospital for tests.[135]

10 other cases are being investigated as swine flu in Nottingham.[136]

On 27 April the UK Health Secretary Alan Johnson told the House of Commons that 25 possible cases had been reported. He also stated that protective facemasks were not planned, as despite their use in Mexico, scientific evidence did not suggest that they proved an effective preventative measure.[137]

On the evening of 27 April Scottish Health Minister Nicola Sturgeon reported that seven people who were in contact with the two confirmed Scottish cases are showing flu-like symptoms.[138][139]

North America

Outbreak evolution in North America:
  Deaths
  Confirmed cases
  Unconfirmed or suspected cases

Canada

Main article: 2009 swine flu outbreak in Canada

Four cases of swine flu have been confirmed in Nova Scotia and two in British Columbia.[140] Nova Scotia's chief medical officer, Dr. Robert Strang, said on 26 April that the National Microbiology Laboratory in Winnipeg confirmed late the previous day, that four young people in the province were recovering from "relatively mild" cases of the disease. The four all attended King's-Edgehill preparatory school in Windsor; and one of the four infected students had been on a recent school trip to the Yucatán Peninsula.[140][141] There is evidence that the disease is spreading beyond the first 4 Nova Scotia cases, as friends and relatives are starting to show symptoms. Dr Robert Strang indicated that he expects the diseases to spread to the rest of Nova Scotia within a few weeks[142]

Dr. Michael Gardam, director of infectious disease prevention and control at Ontario's public health agency, said in an interview with the CBC that an outbreak of swine flu in Ontario, Canada's most populous province, would not be as serious as the 2003 SARS epidemic.[143] In preparing for and dealing with an influenza pandemic, the Public Health Agency of Canada follows the WHO's categories, but has expanded them somewhat.[144] Despite initial reports of two swine influenza cases in a Montreal hospital, an official on the Montreal regional health board confirmed negative results for all quarantined patients at the hospital and that no quarantines were currently in effect at the hospital.[145]

Canada's Chief Public Health Officer, Dr. David Butler-Jones, stated that the six affected Canadians suffered from only mild symptoms and have already started to recover. Butler-Jones warned against complacency though, stating that the fact that only mild cases have been reported so far "doesn’t mean we won’t see either some more severe illness or potentially deaths."[146] In both provinces, the cases either involved people who had recently returned from Mexico or those in close contact with them.[147]

Mexico

Main article: 2009 swine flu outbreak in Mexico

Dr. Jose A. Cordova Villalobos, Mexico's Secretary of Health has stated that since March 2009, there have been over 1,995 suspected cases and 149 deaths, with 20 confirmed to be linked to a new swine influenza strain of Influenza A virus subtype H1N1.[148][149] As of April 26 there have been 1,614 cases, with 103 deaths and about 400 patients in hospital. Around two-thirds of the sick patients had recovered.[150]

Mexican soldiers distributing protective masks to citizens

Soldiers mobilized by the Mexican government have handed out six million surgical masks to citizens in and around Mexico City.[151] On April 24, 2009, schools (from pre-school to university level) as well as libraries, museums, concerts and any public gathering place, were shut down by the government in Mexico City and the neighboring State of Mexico to prevent the disease from spreading further; the schools in Mexico City, the State of Mexico, and the state of San Luis Potosí will remain closed until at least May 5.[152] Marcelo Ebrard, Mexico City's mayor, has also asked all night-life operators to shut down their places for ten days to prevent further infections.[153] José Ángel Córdova, federal Secretary of Health, said on April 24 that schools will probably be suspended for at least the following week then, and that it will take around ten days to see the evolution of the virus' behavior, and to consider other measures after such.[154] On April 25, President Felipe Calderón declared an emergency which granted him the power to suspend public events and order quarantines.[155] Hours later, Córdova announced classes in Mexico City would be officially suspended through May 6.[156] On 26 April, Natividad Gonzalez Paras, governor of the northeastern State of Nuevo León, announced that state-wide schools will remain closed until 6 May, and established a quarantine system in airports, central bus stations and the creation of observation points mainly in the southern part of the state at the nearest highways to the borders with other states, in order to realize tests conducted on people arriving from other states. However, as for April 27, there are no confirmed reported cases of infection in this state.[157]

On 26 April, the World Bank announced US$ 25 million in immediate aid loans to Mexico, an additional US$ 180 million for long-term assistance to address the outbreak, and advice on how other nations have responded to similar crises.[151]

On 27 April, the Secretaría de Educación Pública announced that all schools in Mexico will remain closed at least until May 6.[158]

United States

Main article: 2009 swine flu outbreak in the United States
CDC conference with the media on the swine flu outbreak on April 25, 2009

Officials in the United States confirmed that seven people in California, two students from a high school in Texas, and a married couple in Kansas were infected with the A/09(H1N1) swine flu; all have recovered.[159] One additional student from the same high school in Texas is suspected of probably having the influenza strain. St. Francis Preparatory School, a private school in New York, has 28 confirmed cases of swine flu.[160] The cases in Kansas and New York are linked to travel to Mexico; most of the cases in California and Texas are not linked and may reflect localized outbreaks of this virus in those areas.[161] One case has been confirmed in Elyria, Ohio.[159] A public health emergency has been declared, but it was said that this is standard procedure in cases as divergent as the recent inauguration and flooding.[162]

In contrast with the cases in Mexico, American cases have not yet resulted in any deaths.[65][163] By April 27, all 20 of those cases had recovered.[164]

The United States of America has declared a state of Public Health Emergency. According to the New York Times, "the emergency declaration frees resources to be used toward diagnosing or preventing additional cases and releases money for more antiviral drugs," including the transfer of approximately 12 million influenza medications from a federal stockpile to states.[151][165] The U.S. plans to follow a guidebook developed over the past five years to fight a pandemic flu, such as H5N1. The situation has developed rapidly with the White House initially looking into the matter according to press releases on April 24, but rapidly adopting a more serious stance as the WHO and CDC issue stronger recommendations.

Oceania

Australia

As of 28th April 2009, Australia has reported at least 70 suspected cases of the 2009 swine flu in the country, that are being tested. Currently Australia has stockpiled 8.7 million doses of Tamiflu and Relenza [166]; and has imposed strict entry restrictions to passengers from North America and New Zealand.[167]

New Zealand

Following a three-week language trip to Mexico, ten students from Rangitoto College, a secondary school in North Shore City, Auckland, exhibited influenza symptoms. All 22 students and three accompanying teachers from the trip are currently in home isolation, with oseltamivir provided to the patients and those in contact with them. 10 students have tested positive for an influenza A virus,[168][169] with 3 of them positive for swine flu.[170] A further five people are being tested for influenza A.[171]

New Zealand has a well developed Influenza Pandemic action plan.[172] New Zealand has upgraded its influenza pandemic alert status to code yellow.[173] The national stockpile of 1.4 million doses of oseltamivir has been released to regional health authorities. New Zealand is currently following a policy of border control and cluster control via voluntary quarantine and treatment of contacts with oseltamivir.

South America

Argentina

All passengers arriving to the country from Mexico and United States must fill out a form to be located in case they show symptoms of flu according to an Epidemic Alert order issued by The Ministry of Health.[174] In the meantime the Goverment plans to suspend all flights originated from Mexico in the next 72 hours as a precautionary measure.[175]

Brazil

Two people who had arrived in Brazil from Mexico with symptoms of an undefined illness were hospitalized in São Paulo on April 25. It was initially suspected that they were suffering from the swine flu virus.[176] The Brazilian Ministry of Health later issued a press release stating that while the exact cause of the two patients illnesses remained unknown, they "did not meet the definition of suspected cases of swine influenza because they did not have signs and symptoms consistent with the disease: fever over 39 °C, accompanied by coughing and/or a headache, muscle and joint pain."[177]

The press release also stated that airports would monitor travelers arriving from affected areas, under the direction of the National Sanitary Surveillance Agency (ANVISA). Air crews are also being trained on signs and symptoms of swine influenza so that passengers displaying symptoms may receive guidance from ANVISA upon arrival.

Chile

On April 27, the Assistant Secretary of Health Jeanette Vega, confirmed that there are eight suspected cases of swine influenza in the country, which are being examined at the Hospital del Tórax in Santiago. Five other cases have been dismissed by the authorities. [178]

Colombia

The Minister of Social Protection, Diego Palacio Betancourt, announced on April 26, 2009, that 12 suspect cases have been detected, 9 in Bogotá and 3 on the Caribbean coast. Samples of the virus have been sent to the USA for comparisons and analysis. Results of the testing are expected in a few days.[179]

Peru

The Governor of Callao, Alex Kouri, ordered that all passengers from any infected country, mainly Mexico and USA, must be checked before their arrival on Peruvian territory. Also, the Peruvian government must be warned of any case or symptom of fever. This step is in order to prevent any infections, since the main port and airport of Peru are located in Callao. Also, the government has prepared a special area at the Hospital "Daniel Alcides Carrión" to treat cases of this disease.[180]

The first suspicious case has been detected in the morning of April 27, 2009. It was a Peruvian woman who returned from Mexico.[181]

See also

References

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