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A TIME'S MEMORY - Flu, Bugs & Other Accidents Blog - Year: XV

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1 Aug 2009

Pandemic influenza (H1N1) 2009 - Update 31 July 2009, 17:00 hours CEST (ECDC, edited)

[Original Full Document: LINK. EDITED.]

ECDC SITUATION REPORT

Pandemic influenza (H1N1) 2009 - Update 31 July 2009, 17:00 hours CEST


Main developments in past 24 hours
  • 2403 new cases, including 738 new cases from Germany, 705 from the United Kingdom and the first death in France were confirmed and reported from the EU and EFTA countries, reaching a total of 26,424;
  • 3273 new cases including 20 fatal cases, were reported from non-EU and EFTA countries, reaching a cumulative total of 156,902 cases;
  • ECDC compiled an update of the analysis of individual case notification, attached to this report.

This report is based on official information provided by the national public health websites, or through other official communication channels. An update on the number of confirmed cases as of 30 July 2009, 17:00 hours CEST, is presented in Table 1 and Table 2.

Disclaimer:

The number of confirmed cases reported is based on laboratory test results, except for the US. Depending on the national laboratory testing policies, the actual number of cases by country may therefore be higher. Several countries have now announced recommendations on treatment on clinical signs only and focused laboratory testing only for specific population groups or in outbreaks. For these countries, the reported numbers of cases presented in this report will severely underestimate the true incidence in the country and will not be comparable to countries still recommending laboratory tests of all suspected influenza cases.


Epidemiologic update

Out of the 31 EU and EFTA countries, 30 countries have reported a total of 26,424 confirmed cases of influenza A(H1N1)v infection, including 39 deaths. In the past 24 hours, 2,403 new cases and the first fatal case in France were reported from the EU and EFTA countries. Germany reported 738 new cases and the United Kingdom 705.

Outside of the EU and EFTA countries, a total of 3273 new cases have been reported within the last 24 hours. In total, 156,902 cases including 1109 fatal cases have been reported from non-EU and EFTA countries.

Globally, the total number of confirmed and reported influenza A(H1N1)v cases to date is 183,326, including 1,148 deaths.


Other developments

ECDC compiled today an update on the analysis of individual case reports provided by Member States, attached to this report.


Table 1: Reported new confirmed cases and cumulative number of influenza A(H1N1)v as of 31 July 2009, 16:00 hours (CEST) in the EU and EFTA countries

[Country - Confirmed cases reported in the last 24h - Cumulative number of confirmed cases - Deaths among confirmed cases*]
  1. Austria 22 - 153 - ...
  2. Belgium ... - 126 - 1
  3. Bulgaria ... - 36 - ...
  4. Cyprus ... - 297 - ...
  5. Czech Republic 6 - 95 - ...
  6. Denmark 7 - 254 - ...
  7. Estonia 1 - 40 - ...
  8. Finland 2 - 189 - ...
  9. France** ... - 719 - 1
  10. Germany 738 - 6062 - ...
  11. Greece 210 - 730 - ...
  12. Hungary 4 - 86 - 1
  13. Iceland 5 - 51 - ...
  14. Ireland ... - 276 - ...
  15. Italy 357 - 975 - ...
  16. Latvia 1 - 19 - ...
  17. Lithuania 7 - 22 - ...
  18. Luxemburg ... - 52 - ...
  19. Malta 7 - 157 - ...
  20. Netherlands*** 153 - 517 - ...
  21. Norway 54 - 471 - ...
  22. Poland 12 - 87 - ...
  23. Portugal 28 - 291 - ...
  24. Romania 21 - 164 - ...
  25. Slovakia 5 - 52 - ...
  26. Slovenia 5 - 128 - ...
  27. Spain ... - 1538 - 6
  28. Sweden 14 - 511 - ...
  29. Switzerland 39 - 462 - ...
  30. United Kingdom 705 - 11864 - 30
  • Total 2403 - 26424 - 39
  • Note: cases reported in the EU and EFTA countries correspond to the EWRS notifications by Member States or Ministry of Health websites.
  • (*) Deaths are included in the cumulative number of confirmed cases
  • (**) Cases reported from France include those reported from Reunion-Mayotte (26), Antilles-Guyane (9), French Polynesia (16) and French New Caledonia (112).
  • (***) Cases from the Netherlands include those reported from Aruba and the Dutch Antilles

Table 2: Reported cumulative number of confirmed cases and deaths of influenza A(H1N1)v as of 31 July 2009, 16:00 hours (CEST) outside of the EU and EFTA area

[Country - Confirmed cases reported in the last 24h - Cumulative number of confirmed cases - Deaths among confirmed cases*]
  • OTHER EUROPEAN COUNTRIES and CENTRAL ASIA
  1. Albania ... - 3 - ...
  2. Andorra ... - 1 - ...
  3. Azerbaijan ... - 2 - ...
  4. Bosnia and Herzegovina ... - 2 - ...
  5. Channel Islands ... - 16 - ...
  6. Croatia ... - 52 - ...
  7. Georgia ... - 6 - ...
  8. Former Yugoslav Republic of Macedonia ... - 14 - ...
  9. Isle of Man ... - 11 - ...
  10. Kazakhstan ... - 14 - ...
  11. Kosovo ... - 1 - ...
  12. Moldova ... - 1 - ...
  13. Monaco ... - 1 - ...
  14. Montenegro ... - 18 - ...
  15. Russia ... - 28 - ...
  16. Serbia ... - 115 - ...
  17. Ukraine ... - 1 - ...
  • MEDITERRANEAN AND MIDDLE-EAST
  1. Algeria ... - 14 - ...
  2. Bahrain 15 - 98 - ...
  3. Egypt ... - 226 - 1
  4. Iran ... - 61 - ...
  5. Iraq ... - 49 - ...
  6. Israel ... - 1520 - 1
  7. Jordan ... - 79 - ...
  8. Kuwait ... - 145 - ...
  9. Lebanon ... - 154 - 1
  10. Libya ... - 9 - ...
  11. Morocco ... - 53 - ...
  12. Occupied Palestinian Territory ... - 104 - ...
  13. Oman ... - 19 - ...
  14. Qatar ... - 42 - ...
  15. Saudi Arabia ... - 294 - 2
  16. Syria ... - 5 - ...
  17. Tunisia ... - 10 - ...
  18. Turkey ... - 116 - ...
  19. United Arab Emirates ... - 110 - ...
  20. Yemen ... - 10 - ...
  • AFRICA
  1. Botswana ... - 4 - ...
  2. Cape Verde ... - 6 - ...
  3. Ethiopia ... - 4 - ...
  4. Gabon ... - 1 - ...
  5. Ivory Coast ... - 2 - ...
  6. Kenya ... - 22 - ...
  7. Mauritius ... - 2 - ...
  8. Namibia ... - 4 - ...
  9. Seychelles ... - 3 - ...
  10. South Africa ... - 151 - ...
  11. Sudan ... - 2 - ...
  12. Swaziland ... - 2 - ...
  13. Tanzania ... - 8 - ...
  14. Uganda ... - 8 - ...
  • NORTH AMERICA
  1. Canada ... - 10449 - 59
  2. Mexico 423 - 16442 - 146
  3. **USA ... - 43771 - 302
  • CENTRAL AMERICA AND CARIBBEAN
  1. Antigua and Barbuda ... - 3 - ...
  2. Bahamas ... - 29 - ...
  3. Barbados ... - 23 - ...
  4. Belize ... - 23 - ...
  5. Bermuda ... - 4 - ...
  6. British Virgin Islands ... - 2 - ...
  7. Cayman Islands ... - 43 - 1
  8. Costa Rica ... - 668 - 21
  9. Cuba 14 - 234 - ...
  10. Dominica ... - 1 - ...
  11. Dominican Republic ... - 131 - 3
  12. El Salvador ... - 556 - 9
  13. Grenada ... - 1 - ...
  14. Guatemala 100 - 558 - 10
  15. Guyana ... - 5 - ...
  16. Haiti ... - 3 - ...
  17. Honduras ... - 169 - 4
  18. Jamaica ... - 53 - 2
  19. Nicaragua ... - 432 - ...
  20. Panama ... - 571 - 2
  21. Saint Kitts and Nevis ... - 3 - 1
  22. Saint Lucia ... - 3 - ...
  23. Saint Vincent ... - 1 - ...
  24. Suriname ... - 14 - ...
  25. Trinidad-Tobago ... - 97 - ...
  • SOUTH AMERICA
  1. Argentina ... - 3056 - 165
  2. Bolivia 25 - 946 - 7
  3. Brazil ... - 1566 - 34
  4. Chile ... - 11641 - 79
  5. Colombia 11 - 270 - 17
  6. Ecuador ... - 696 - 17
  7. Paraguay ... - 195 - 14
  8. Peru 737 - 4029 - 29
  9. Uruguay ... - 550 - 22
  10. Venezuela ... - 426 - 2
  • NORTH-EAST AND SOUTH ASIA
  1. Afghanistan ... - 15 - ...
  2. Bangladesh ... - 30 - ...
  3. Bhutan ... - 2 - ...
  4. China (mainland) 87 - 2090 - ...
  5. Hong Kong SAR China 214 - 3673 - 1
  6. India 11 - 509 - ...
  7. Japan ... - 5022 - ...
  8. Macao SAR China 7 - 181 - ...
  9. Maldives ... - 1 - ...
  10. Nepal ... - 17 - ...
  11. South Korea 35 - 1399 - ...
  12. Sri Lanka ... - 53 - ...
  13. Taiwan ... - 1280 - 1
  • SOUTH-EAST ASIA
  1. Brunei Darussalam 452 - 786 - 1
  2. Cambodia ... - 17 - ...
  3. Indonesia 16 - 495 - 1
  4. Laos Peoples Democratic Republic ... - 51 - 1
  5. Malaysia 69 - 1371 - 4
  6. Myanmar 1 - 10 - ...
  7. Philippines 539 - 3207 - 8
  8. Singapore ... - 1217 - 5
  9. Thailand ... - 8879 - 65
  10. Vietnam 31 - 794 - ...
  • AUSTRALIA AND PACIFIC
  1. Australia 559 - 21668 - 61
  2. Cook Islands ... - 1 - ...
  3. Fiji ... - 97 - ...
  4. Micronesia ... - 1 - ...
  5. New Zealand 28 - 2797 - 13
  6. Papua New Guinea ... - 1 - ...
  7. Republic of Palau ... - 1 - ...
  8. Samoa ... - 37 - ...
  9. Solomon Islands ... - 2 - ...
  10. Tonga ... - 9 - 1
  11. Vanuatu ... - 3 - ...
  • TOTAL 3273 - 156902 - 1109
  • Note: cases reported in non-EU and EFTA countries correspond to cases published on Ministry of Health websites, or through WHO, or through credible media source quoting national authorities. Therefore, some of these cases may be taken out at a later stage if not validated.
  • (*) Deaths are included in the cumulative number of confirmed cases
  • (**) Cases in the US include both probable and confirmed cases. They also include confirmed cases from Puerto Rico, American Samoa, Guam and Virgin Islands.
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ECDC SURVEILLANCE REPORT

PANDEMIC (H1N1) 2009 Weekly report - Individual Case Reports - EU and EEA countries - As of 27 July 2009


Summary

The pandemic of influenza A(H1N1)v is spreading despite the influenza season is over. Community transmission is ongoing in several of the 27 EU and three European Economic Area (EEA) and EFTA countries, Iceland, Liechtenstein and Norway, and transmission between countries is frequent.

The most affected age groups are persons under 20 years of age.

Persons 60 years and older are less frequently affected, but are more frequently hospitalised and do have a higher proportion of underlying disease.

The move to mitigation strategy in nearly half of the countries severely affects the current surveillance of individual cases. Ongoing monitoring of the disease is urgently needed and change of surveillance is currently implemented.


Acknowledgement

These data were provided by the national contact points for surveillance and for the Early Warning and Response System of the EU and EEA countries. ECDC wishes to acknowledge the continuous commitment and effort of all these individuals and their teams in ensuring the timely reporting of valid individual data from their respective countries.

Due to the efforts countries made to update aggregated information through EWRS and their websites the continuous active monitoring of the pandemic since its start by the ECDC team was possible.


Introduction

On 21 April 2009, the United States Centers for Disease Control and Prevention (US CDC) reported two cases of influenza due to a new virus strain of mixed swine, avian and human origin, the so-called new influenza A(H1N1) virus (hereafter named A(H1N1)v virus) [1].

On 25 April, the European Centre for Disease Prevention and Control (ECDC) published a risk assessment, started developing tools to monitor the situation and support the countries of the European Union (EU) and European Free Trade Association (EFTA), and initiated its first situation report distributed daily to more than 700 stakeholders since then.

The World Health Organisation (WHO) raised its pandemic alert level to phase 4 on 27 April and up-scaled again to phase 5 on 29 April. On 11 June, phase 6 was announced by WHO.

Aggregated and individual case reporting was implemented by ECDC using the Early Warning and Response System (EWRS). A workshop was held on 14/15 July at ECDC to discuss further surveillance strategies.

The objective of this report is to present the epidemiological situation in the 27 EU and the three countries in the European Economic Area (EEA) and EFTA, Iceland, Liechtenstein and Norway, hereafter called the EU+3 countries, on the basis of the surveillance data provided by the EU+3 countries through individual and aggregated case reports. Country specific reports are available [1-6].


Methods

Data used in this analysis of the epidemiological situation in the EU+3 countries, as of Monday 27 July 2009 10:00 CEST, include laboratory confirmed individual case reports posted by countries in the Early Warning and Response System (EWRS) and aggregated case reports provided daily through the EWRS or through other official communication channels.

Confirmed cases are defined as persons in whom the infection has been confirmed by RT-PCR, or by viral culture or by a four-fold rise in influenza A(H1N1)v-specific neutralising antibodies. The latter implies, according to the EU case definition, the need for paired sera from the acute phase of illness and from the convalescent stage 10-14 days later [2].

While countries with fewer cases are uploading data directly into the surveillance database at ECDC, Spain, the United Kingdom (UK), (who both have high number of cases) Belgium, Slovenia and Malta, are providing extracts from their national databases, which are then imported into the ECDC database. Re-coding of some of the variables is necessary

Cases which are not explicitly reported having been exposed during travel in an affected country (imported or travel related cases) are considered to have been infected in their own country.

Due to the fact that detailed symptoms are not available for the majority of cases, and that no denominator can be defined, this analysis describes groups of symptoms rather than detailed symptoms. The distribution of symptoms is described among symptomatic patients only. The proportion of asymptomatic persons cannot be assessed with the current data available.


[Table 1 - Reported aggregated and individual number of cases of influenza A(H1N1)v infection, proportion of individually reported cases, last updates and date of changing to mitigation strategy of EU+3 countries, as of 27 July 2009]

[Country - Aggregated case reports: Total - Individual case reports: Total - % - Last update - Date of changing to mitigation strategy]
  1. Austria 97 - 64 - 66 - 21 July - ...
  2. Belgium 126 - 124 - 98 - 13 July - 13 July
  3. Bulgaria 29 - 26 - 90 - 23 July - ...
  4. Cyprus 297 - 205 - 69 - 13 July - 17 July
  5. Czech Republic 43 - 40 - 93 - 27 July - 9 July
  6. Denmark 180 - 97 - 54 - 17 July - 7 July
  7. Estonia 34 - 31 - 91 - 26 July - ...
  8. Finland 167 - 164 - 98 - 24 July - 22 July
  9. France** 628 - 554 - 88 - 22 July - 23 July
  10. Germany 2,844 - 704 - 25 - 10 July - ...
  11. Greece 520 - 0 - 0 - 16 July - ...
  12. Hungary 59 - 47 - 80 - 24 July - ...
  13. Iceland 23 - 4 - 17 - 22 June - ...
  14. Ireland 205 - 107 - 52 - 23 July - 16 July
  15. Italy 618 - 134 - 22 - 9 July - ...
  16. Latvia 12 - 1 - 8 - 25 June - ...
  17. Lithuania 10 - 10 - 100 - 24 July - ...
  18. Luxemburg 38 - 35 - 92 - 23 July - ...
  19. Malta 123 - 106 - 86 - 20 July - 8 July
  20. Netherlands*** 273 - 197 - 72 - 22 July - 24 July
  21. Norway 245 - 60 - 24 - 16 July *
  22. Poland 57 - 47 - 82 - 25 July - ...
  23. Portugal 226 - 149 - 66 - 24 July - ...
  24. Romania 107 - 75 - 70 - 24 July - ...
  25. Slovakia 40 - 35 - 88 - 23 July - ...
  26. Slovenia 102 - 7 - 7 - 3 July - ...
  27. Spain 1,538 - 113 - 7 - 14 May - ...
  28. Sweden 390 - 172 - 44 - 15 July - 15 July
  29. United Kingdom 11,159 - 6,002 - 54 - 3 July - 10 July
  • Total 20,190 - 9,310 - 46
  • (*) Norway never used containment strategy, but surveillance data are considered reliable
  • (**) Cases reported from France include those reported from Reunion-Mayotte (10), Antilles-Guyane (9), French Polynesia (5) and French New Caledonia (46)
  • (***) Cases from the Netherlands include those reported from Aruba and the Dutch Antilles
When analysing the individual data by country of reporting (figure 1), a drastic decrease in the number of cases in the 3rd week of June is due to the fact that the last report from the UK was received on 3 July.

[Figure 1 - Number of cases of individual reports by onset of disease and country of reporting, 20 April until 27 July, 2009 (...)]


Imported cases

Among the 2,393 travel related cases, only in 33 (1.4%) no probable country of infection was reported. More than half of the cases (1319), reported a travel to the North American sub-continent, 1,022 (76%) to the USA, 221 (17%) to Mexico and 62 (5%) to Canada. The rest reported a travel to more than one country. Cases with travel history to Mexico contributed mainly to the early imported cases, whereas cases with travel history to the US and Canada accounted for later cases imported from the North American sub-continent (figure 2).

[Figure 2 - Number of travel related cases by onset of disease and continent of travel, 20 April until 27 July, 2009 (n=2,393) (...)]

A travel history within the EU+3 countries was the second most common travel destination of imported cases and accounted for 28% of travel related cases (674). More than 1/3 of travel related cases to another EU country reported Spain as their destination (253) and nearly as many the UK (250). Cyprus as travel destination accounted for 9% of cases (58), followed by Greece, 4% (24), France (23) and Germany (19). Less than 10 cases with travel exposure to the following countries were reported: Belgium, Bulgaria and Ireland (7 each), Italy and Poland (5 each), Malta, Portugal and Netherlands (2 each), Austria, Norway and Slovakia (1 each). Seven cases reported a travel to more than one EU+3 country.

Central and South American travel destinations accounted for 6% or travel related cases in EU+3 countries (153): Argentina (52), Dominican Republic (35), Brazil (26), Chile (20), other countries with less than 10 cases.

Other frequent travel destinations were to the Southern hemisphere (3%) and Asian countries (3%): Australia (63), New Zealand (16), Thailand (41), Philippines (10), from all other countries of the Southern hemisphere less than 10 cases were imported to EU+3 countries. Four percent (87) of travel related cases in the EU reported other destinations world-wide (figure 2) but less than 10 cases had exposure in these countries (figure 3).

[Figure 3 - Number of travel related cases by country, 20 April until 27 July, 2009 (n=2,360) (...)]

The median age of travel related cases is 25 years, ranging from 1 month to 82 years of age. More than 1/3 of cases were reported in the 20 to 29 year age group. Nine percent of cases were older than 50 years of age. The male to female ratio of travel related cases was 1.2 (table 2).

[Table 2 - Age and gender distribution of travel related, 20 April and 27 July (n=2,342)]

[ Age group - Female - Male - Total - Percentage of total]
  • Under 10 - 82 - 122 - 204 - 8.7
  • 10 to 19 - 222 - 222 - 444 - 19.0
  • 20 to 29 - 396 - 483 - 879 - 37.5
  • 30 to 39 - 165 - 187 - 352 - 15.0
  • 40 to 49 - 92 - 151 - 243 - 10.4
  • 50 to 59 - 76 - 72 - 148 - 6.3
  • ≥60 - 29 - 43 - 72 - 3.1
  • Total 1,062 - 1,280 - 2,342 - 100

Domestic cases

The majority of cases (74%, 6,918) were classified as domestic cases, who had either no travel history (96%, 6,665) or unknown travel history (4%, 253).

In the EU+3 countries the percentage of domestic cases among individually reported cases was 74%, with wide variation among countries: 6% in Luxembourg and Slovakia and 94% in Cyprus. No domestic cases were reported from Latvia and Slovenia, Greece did not report individual cases (table 3).

[Table 3 - Aggregated and individually reported cases by country and travel exposure, proportion of domestic cases and cumulative incidence of domestic cases, 20 April and 27 July]

[Country - Individually reported cases - Domestic cases individually reported - Percentage of domestic cases among individually reported cases]
  1. Austria 64 - 17 - 27
  2. Belgium 124 - 52 - 42
  3. Bulgaria 26 - 6 - 23
  4. Cyprus 205 - 193 - 94
  5. Czech Republic 40 - 4 - 10
  6. Denmark 97 - 44 - 45
  7. Estonia 31 - 10 - 32
  8. Finland 164 - 29 - 18
  9. France 554 - 240 - 43
  10. Germany 704 - 393 - 56
  11. Greece 0 - ... - ...
  12. Hungary 47 - 14 - 30
  13. Iceland 4 - 1 - 25
  14. Ireland 107 - 11 - 10
  15. Italy 134 - 16 - 12
  16. Latvia 1 - ... - ...
  17. Lithuania 10 - 1 - 10
  18. Luxemburg 35 - 2 - 6
  19. Malta 106 - 76 - 72
  20. Netherlands 197 - 74 - 38
  21. Norway 60 - 9 - 15
  22. Poland 47 - 10 - 21
  23. Portugal 149 - 26 - 17
  24. Romania 75 - 20 - 27
  25. Slovakia 35 - 2 - 6
  26. Slovenia 7 - ... - ...
  27. Spain 113 - 39 - 35
  28. Sweden 172 - 43 - 25
  29. United Kingdom 6,002 - 5,586 - 93
  • Total 9,310 - 6,918 - 74

Most travel related cases with travel history to another EU+3 country reported a previous travel exposure to Spain (256), the UK (251), Cyprus (58), France and Greece (24) (table 3).

The median age of domestic cases is 14 years, ranging from 1 month to 90 years compared to the median age of 25 years of travel related cases. Among the 6,787 cases with known age, 4,325 (64%) are below 20 years of age and less than 5% (296) are 50 years or older. The male to female ratio of domestic cases is 1.1.

The age distribution of domestic and travel related cases is different (figure 4): among travel related cases 64% are younger than 20 years of age compared to 28% of travel related cases (p<0.0001).

[Figure 4 - Distribution by age and travel status, 20 April and 27 July (n=9,137) (...)]


Hospitalisation

Overall in EU+3 countries, 10% of cases were reported having been hospitalised. The percentage of hospitalised cases varied among countries, between 2% in the UK and 96% in Austria and Romania (table 5).

[Table 5 - Number of individually reported cases, number of hospitalised cases and percentage of hospitalised cases by country, 20 April and 27 July]

[Country - Individually reported cases - Hospitalised cases - Percentage hospitalised (%)]
  1. Austria 54 - 52 - 96
  2. Belgium 123 - 12 - 10
  3. Bulgaria 26 - 19 - 73
  4. Cyprus 204 - 46 - 23
  5. Czech Republic 40 - 14 - 35
  6. Denmark 73 - 10 - 14
  7. Estonia 31 - 10 - 32
  8. Finland 162 - 16 - 10
  9. France 394 - 225 - 57
  10. Germany 595 - 100 - 17
  11. Greece* ... - ... - ...
  12. Hungary 47 - 9 - 19
  13. Iceland** ... - ... - ...
  14. Ireland 81 - 3 - 4
  15. Italy 129 - 35 - 27
  16. Latvia* ... - 1 - ...
  17. Lithuania 10 - 2 - 20
  18. Luxembourg 35 - 2 - 6
  19. Malta 106 - 6 - 6
  20. Netherlands 185 - 1 - 1
  21. Norway 60 - 4 - 7
  22. Poland 39 - 34 - 87
  23. Portugal 138 - 95 - 69
  24. Romania 75 - 72 - 96
  25. Slovakia 34 - 23 - 68
  26. Slovenia** ... - ... - ...
  27. Spain* ... - ... - ...
  28. Sweden 125 - 8 - 6
  29. United Kingdom 5,895 - 90 - 2
  • Total 8,661 - 889 - 10
(*) no data available
(**) no cases hospitalised

Cases with underlying disease were more frequently hospitalised (32%) compared to patients without underlying diseases (10%) (n=8,673, p<0.0001).


Complications

The information regarding complications is scarce. Among 1,674 cases with available information 50 (3%) were reported with complications.

Pneumonia was reported in 28 (56%) of those, of which 20 were reported having been admitted to hospital.

In the individual case reports one fatal case is reported, whereas in the aggregated reports 35 deaths during the same period were reported: 30 from the UK, 4 from Spain and one from Hungary.


Clinical presentation

Information on clinical symptoms is available for 5,220 cases. No information is available from Belgium and Slovenia. Only four cases were reported to be asymptomatic. Respiratory symptoms were the most frequently reported symptoms among symptomatic cases (87%), followed by fever (82%) and gastro-intestinal symptoms (13%).

Gastro-intestinal symptoms were more frequently reported from cases less than 20 years of age (15%) when compared with older cases (12%) (p<0.001).


Treatment and prophylaxis

Among 8,009 cases with available information on antiviral treatment, 55% were reported having received antiviral treatment. The proportion of cases receiving treatment varied between countries: 15% of cases in Slovakia to 100% in Estonia, Slovenia and Latvia (only one case).


Underlying preconditions

In total, 290 cases were reported having underlying preconditions, which are considered risk factors for severe disease. Among the 192 cases with available information about underlying precondition, lung disease was the most frequently reported condition (57%, n=109) followed by pregnancy (13%, n=25), diabetes (9%, n=17) and heart disease (8%, n=16).

Significantly more cases with underlying preconditions were treated (75%) when compared with previous healthy cases (55%) (p<0.0001).

The proportion of cases with underlying disease increased by age: in the age group of 60 years and older 20% were reported to have an underlying disease (table 6).

[Table 6 - Number of individually reported cases, number of cases with underlying preconditions and proportion by age group]

[Age groups - Individually reported cases - Cases with underlying preconditions - Percentage (%)]
  • under 10 - 1,996 - 26 - 1.3
  • 10 to 19 - 2,978 - 63 - 2.1
  • 20 to 29 - 2,172 - 64 - 2.9
  • 30 to 39 - 829 - 49 - 5.9
  • 40 to 49 - 645 - 32 - 5.0
  • 50 to 59 - 360 - 23 - 6.4
  • 60+ - 157 - 32 - 20.4
  • Total 9,137 - 289 - 3.2

The vaccination status was reported from 7,792 cases, of which 2.5% (n=193) were reported having been vaccinated against seasonal influenza. The vaccination coverage was significantly higher among persons with reported underlying preconditions (30%) compared to previous healthy cases (2.3%) (p<0.0001).


Discussion

The fact that many countries are moving to mitigation strategy will significantly influence the surveillance activities. Mitigation also considers change of surveillance to sentinel reporting of influenza like illness rather than exhaustive reporting of cases.

The last report from the UK was received on 3 July, which accounted for the majority of reported cases. The UK reported to have moved from containment to mitigation on 10 July which also resulted in a change of surveillance. The decrease in the number of cases reported during the last week in June is due to the end of reporting UK data which accounted for nearly 2/3 of cases. The drop in the epidemic curve in July is due to due to the reporting delay, but also due to the fact that nearly half of the countries have changed to mitigation, which includes change of surveillance strategy.

The data quality of underlying preconditions may be not accurate especially when the number of cases is high in a country (personal communication from the UK).


Conclusion

The ongoing pandemic is continuing to spread and the number of cases is rapidly increasing despite the fact that the seasonal influenza season is considered to be over. In several countries, in-country transmission is probably ongoing.

Persons with underlying preconditions are more vulnerable group for complications and severe disease and are getting more frequently antiviral treatment and are more frequently vaccinated against seasonal influenza. Nevertheless, the estimated seasonal influenza vaccination coverage is well below its target to be achieved in risk groups.

The age groups affected are important to be continuously monitored to help guiding target age groups for pandemic vaccination with initially limited vaccines.

The surveillance of individually reported cases will soon stop and other surveillance strategies are needed. A meeting with stakeholders from EU+3 countries was recently held in Stockholm, and surveillance of ILI and SARI (severe acute respiratory infection) will be two important strategies.

Serologic studies will be needed to assess the proportion of asymptomatic cases, and the ability of asymptomatic cases to transmit the infection. In addition, specific other studies are needed to answer the many open questions about this disease.


References

[1] Surveillance Group for New Influenza A(H1N1) Virus Investigation and Control in Spain. New influenza A(H1N1) virus infections in Spain, April-May 2009. Euro Surveill. 2009;14(19):pii=19209. Available online: http://www.eurosurveillance.org /ViewArticle.aspx?ArticleId=19209
[2] Health Protection Agency, Health Protection Scotland, National Public Health Service for Wales, HPA Northern Ireland Swine influenza investigation teams. Epidemiology of new influenza A (H1N1) virus infection, United Kingdom, April – June 2009. Euro Surveill. 2009;14(22):pii=19232. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19232
[3] HPA Weekly pandemic flu update, 16 July 2009 http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1247728933406?p=1231252394302
[4] InVS France, BULLETIN EPIDEMIOLOGIQUE GRIPPE A(H1N1), Date : 15 juillet 2009 à 11h http://www.invs.sante.fr/display/?doc=surveillance/grippe_dossier/points_h1n1/grippe_A_h1n1_150709/index.html
[5] Surveillance Group for New Influenza A(H1N1) Virus Investigation in Italy. Virological surveillance of human cases of influenza A(H1N1)v virus in Italy: preliminary results. Euro Surveill. 2009;14(24):pii=19247. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19247
[6] RKI, Situationseinschätzung zur Neuen Influenza Fallzahlen in Deutschland (Letztes Update 15.07.2009) http://www.rki.de/cln_100/nn_200120/DE/Content/InfAZ/I/Influenza/IPV/Schweineinfluenza__Situation.html

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