Signs of a peak in pandemic flu activity continue in several Northern Hemisphere locations, though transmission is still intensifying in Canada and northern and southern Europe, the World Health Organization (WHO) reported today. Sharp increases were noted in Kazakhstan and Israel; Colombia and Peru also reported increases. More than 99% of subtyped influenza A viruses in Europe are the pandemic strain, and a decreasing number of seasonal viruses are being detected in China and Southeast Asia. [Nov 20 WHO pandemic update]

In a letter yesterday, the American Public Health Association (APHA) asked President Obama to resist efforts to change current CDC guidance on respiratory protection for healthcare workers caring for H1N1 patients, which emphasizes face-fitting N-95 respirators over surgical masks. The APHA said it "supports not only the current guidance," but the process by which the guidance was derived. This stance fits respiratory-protection language in a 2006 APHA policy statement on pandemic preparedness. [Nov 19 APHA letter]

A study published in CMAJ (Canadian Medical Association Journal) found that asthma "appears to be a significant risk factor for severe disease" in children with H1N1 flu, according to the authors. In comparing 58 children hospitalized for H1N1 with 200 children admitted with seasonal flu, the authors found little difference in flu severity between the groups. But 22% of children admitted with H1N1 had asthma, compared with 6% of those admitted with seasonal flu. [Nov 19 CMAJ study abstract]

Oklahoma has had its first seasonal flu-related death of the season, showing that the seasonal and pandemic strains are both circulating in the state, according to a report today by The Oklahoman newspaper. State epidemiologist Dr. Kristy Bradley said five more pandemic flu deaths were reported in the state in the past week, but flu activity is slowing, with fewer flu-related hospitalizations and doctor visits. [Nov 20 Oklahoman report]

GlaxoSmithKline has withdrawn a 170,000-dose lot of H1N1 vaccine distributed in Canada because of an unusual number of allergic reactions, CTV News reported today. Health officials reported six anaphylactic reactions to doses from the lot, versus an expected rate of only one or two, the story said. The company asked provinces to set aside the doses so it can test them. Manitoba's chief medical officer of health said the reactions were brief and all the patients recovered. [Nov 20 CTV report]

After one of China's top flu researchers, Zhong Nanshan, said the country might be underreporting its pandemic flu deaths, the Chinese health ministry said today that anyone concealing H1N1 fatalities would be severely punished, Reuters reported. Earlier this month the ministry adopted a new policy that deaths in patients with confirmed H1N1 would be attributed to the virus, even if they had other conditions. Zhong had said some facilities weren't testing for H1N1 in severe pneumonia cases. [Nov 20 Reuters story]

In a reversal of earlier advice, Europe's drug regulatory agency said today that a single dose of the approved adjuvanted H1N1 vaccines may be sufficient in most adults and older children. In October the agency had affirmed an earlier two-dose recommendation. But today regulators said a single dose can be used in adults between ages 18 and 60, and also in children from age 9 (for Focetria) or 10 (for Pandemrix). They said a single dose of Pandemrix is also sufficient for elderly people. [Nov 20 European Medicines Agency release]

The American College Health Association (ACHA) today reported the first two deaths from flu-like illness in college students, but said new cases last week decreased 27% from the previous week. All but five states reported decreases. The report for the week ending Nov 13 said 21.3 new cases of flu-like illness per 10,000 students were reported. There were 12 hospitalizations among the 6,373 new infections. More schools reported access to vaccine, but in very small amounts. [ACHA report for week ending Nov 13]

H1N1 cases in China have risen sharply, despite aggressive quarantine measures, Dr. Michael O'Leary, the World Health Organization's top official in China, told the Associated Press. He said the 70,000 cases and 53 deaths cited by the government are only "minimum numbers." But China's health minister said the control measures helped buy time to develop a vaccine, which is now being given to 1.5 million people a day in an effort to cover 90 million--7% of the population--by the end of the year. [Nov 19 AP report]

German researchers report in Eurosurveillance that a genetic analysis of 300 pandemic H1N1 viruses isolated earlier this year shows that "two closely related but distinct clusters" circulated in most countries simultaneously. Differences were found in the genes for the two surface proteins and four internal proteins. None of the differences involved parts of the genome responsible for known biological functions, and the importance of the findings remains to be determined, the report said. [Nov 19 Eurosurveillance report]

The Centers for Disease Control and Prevention (CDC) today launched what it called its largest-ever public awareness campaign about avoiding illness while traveling, with a focus on H1N1. The agency will urge people to stay home if they are sick, get vaccinated against seasonal flu and against H1N1 if they are in a target group, and to use hygiene measures. The campaign will continue through the holidays and involve a wide range of media, with themes such as "Prevention can be travel-sized." [CDC travel health campaign page]

California officials reported two recent flu deaths in prisoners, one who died Nov 13 in a facility in the southern part of the state and one who died 4 days later in a central California prison, the AP reported yesterday. Preliminary tests confirmed influenza A, and federal officials have said circulating flu strains have been the pandemic virus. Final results are pending. Outbreaks have been reported at prisons, but few deaths have been reported. [Nov 18 AP story]

Hungarian officials declared a flu epidemic yesterday after illness reports rose more than 30% in a week, putting cases above the country's epidemic threshold, Agence France-Presse (AFP) reported yesterday. The number of flu hospitalizations rose to 172. Hungary launched a pandemic vaccine campaign in October using its own vaccine, which is based on a mock-up produced for the H5N1 virus. Children younger than 18 and people in high-risk jobs receive it for free. [Nov 18 AFP article]

The second round of the H1N1 epidemic has begun in Thailand, Public Health Minister Witthaya Kaewparadai said today, according to the Bangkok Post. He said 30% of 200 students tested in the northeastern province of Nakhon Ratchasima were infected. An estimated 8.4 million Thais were infected in the first wave of the outbreak, and the death toll reached 185 yesterday. Kaewparadai said the government bought 2 million doses of vaccine from France and is considering buying 800,000 more. [Nov 19 Bangkok Post report]

Less than half of British patients who have been offered the pandemic vaccine accepted it, Reuters reported today. The findings were based on a poll of 107 family doctors conducted by Pulse magazine. Reasons included fear of side effects and views that the virus is mild. The doctors reported even less acceptance among pregnant women, a high-risk group. The UK government said it's too early to speculate on vaccine uptake rates. [Nov 18 Reuters story]

With 6.6 million doses of H1N1 vaccine given so far, Canada has seen only 36 serious adverse reactions, according to Dr. David Butler-Jones, the country's chief public health officer. He said one person died of an anaphylactic reaction, but it was not yet certain if the vaccine caused it, CTV News reported. Serious events have also included fevers and convulsions. Butler-Jones said 20% of Canada's 31 million people have been vaccinated, which he called the highest proportion of any country. [Nov 17 CTV News report]

In a review of the global cases of oseltamivir (Tamiflu)-resistant H1N1 reported thus far, the European Centre for Disease Prevention and Control (ECDC) said the patients have been geographically dispersed and not linked and the viruses were all susceptible to the other common antiviral, zanamivir (Relenza). Of the 32 cases detailed, two factors may have played a role: reduced immunity and preventive antiviral therapy (prophylaxis). Three cases had no known history of exposure to oseltamivir. [Nov 18 ECDC review]

Santa workers and volunteers are seeking ways to prevent novel H1N1 infection during the holiday season, the Associated Press (AP) reported. One trade group urged its members to use hand sanitizer and take vitamins and the public to keep sick children home. The president of another group asked state lawmaker to consider prioritizing Santa for H1N1 vaccine, given that many are exposed to sick children and are obese, which has been identified as a high-risk condition. [Nov 17 AP story]

Saudi Arabia's Ministry of Islamic Affairs has told Muslim preachers to keep their sermons short because of concern that the H1N1 virus may spread in crowded mosques, Deutsche Presse-Argentur (DPA) reported today. The ministry also instructed imams to use sermons to dispel rumors about how the virus spreads and to urge the faithful to observe good hygiene to prevent infection. [Nov 18 DPA report]

The World Health Organization (WHO) said today that preliminary tests reveal no significant changes in pandemic H1N1 viruses taken from patients in Ukraine. The WHO said that genetic sequencing done in Britain and the US on 34 samples shows that the virus is similar to the one used to make novel H1N1 vaccine, reconfirming the vaccine's efficacy. [Nov 17 WHO statement]

Novartis announced today that US clinical data suggest that half of the company's currently approved unadjuvanted pandemic H1N1 vaccine dose was protective in adults. The trials involve about 4,000 people. The company said it was discussing with US regulators whether reducing the antigen could stretch the vaccine supply. Novartis also said a trial of its MF59-adjuvanted pandemic vaccine showed a single dose was protective in children ages 3 to 8 and adults. [Nov 17 Novartis press release]

US Department of Agriculture researchers report that the pandemic H1N1 virus does not easily infect poultry or spread among them. The researchers inoculated chickens, turkeys, ducks, and quail with the virus, they wrote in Emerging Infectious Diseases. Most of the birds showed no sign of infection; some quail were infected but did not pass the virus to other quail. The authors note that two turkey flocks in Chile were infected earlier this year, but those may have been isolated events. [Nov 16 letter in Emerg Infect Dis]

Health officials in Spain and Greece said both countries launched their pandemic H1N1 vaccine programs yesterday, Agence France-Presse (AFP) reported. Spain bought 37 million doses and is giving first priority to high-risk groups, including pregnant women and health workers. Greece has 700,000 initial doses and is targeting health workers and others in high-risk jobs. Next week's priority group will include pregnant women and people with underlying conditions. [Nov 16 AFP story]

The US Food and Drug Administration (FDA) recently authorized emergency use of two rapid tests for detecting novel H1N1 flu: ELITech's Molecular Diagnostics 2009-H1N1 Influenza A Virus Real-Time RT-PCR and Roche's RealTime Ready Influenza A/H1N1 Detection Set. The tests are designed for respiratory specimens, such as nasal swabs, taken from symptomatic patients. The FDA previously approved six other pandemic flu tests for emergency use. [FDA notices of approval]

Diverse public health programs in Canada, such as support groups and food inspections, are being postponed or suspended as officials redirect staff to H1N1 vaccination efforts, a plan that has been in the works for months, according to a Toronto Globe and Mail story. Health authorities in several provinces have postponed non-flu vaccination programs and travel clinics, while others have limited the impact on public health programs by employing student or retired nurses. [Nov 16 Globe and Mail story]

The WHO and China have agreed to open an influenza research center in Beijing to identify and share knowledge about new strains, officials announced today. Approval to open the center was given last week, when Chinese health officials met with WHO assistant director-general Keiji Fukuda. If the laboratory is designated a WHO collaborating center as planned, it would join a group of such labs in Atlanta, London, Tokyo, and Melbourne. [Nov 17 Bloomberg News report]

Australian researchers who studied hospitalized H1N1 flu patients in seven Melbourne hospitals from May to mid July report that 30 of 112 patients (27%) required intensive care and 3 died. Patients who had multifocal changes on chest x-rays were hospitalized longer and were more likely to need intensive care, according to the Medical Journal of Australia. Twenty-four patients had no known risk factors. Fifteen patients--a quarter of the women--were pregnant or in the postpartum period. [Nov 16 Med J Aust report]

A Canadian Press report probed the wide difference between the numbers of H1N1 flu deaths reported so far and the estimated toll from seasonal flu. Canada, with 4,000 to 8,000 flu-related deaths yearly, has 161 confirmed H1N1 deaths. Experts note that those numbers count different things, because only a small fraction of all seasonal flu-related deaths are directly attributed to flu. In most cases, flu contributes to death from such direct causes as bacterial pneumonia or heart attack. [Nov 15 Canadian Press story]

Mistrust in government and economic fears are two factors that would make it difficult to maintain social distancing during a pandemic, according to findings published today in the American Journal of Bioethics. The study was based on the results of focus groups in four Michigan cities. The authors said more intense efforts are needed to engage the public in pandemic planning. [Am J Bioeth study abstract]

Because many H1N1-related deaths have involved people with chronic respiratory conditions, the World Health Organization (WHO) recently issued a statement to alert tuberculosis (TB) program managers to possible "challenges and synergies" in the effort to control the two diseases. The statement stresses the importance of maintaining TB treatment during a pandemic and notes that lab services developed for TB control can be useful for pandemic H1N1 diagnostics and surveillance. [Nov 12 WHO statement]

Factors such as delays in seeking medical care and getting antiviral medication to outbreak areas contributed to a sudden spike in severe flu-related pneumonia cases in the Ukraine, the New York Times reported. The late-October surge in flu-like illnesses prompted a WHO probe, which found the patterns in line with other countries. Doctors blame the news media and politicians for spreading misinformation, while others say a weak healthcare system played a role. [Nov 13 New York Times story]

Novartis announced that Swiss regulators approved its adjuvanted cell-culture pandemic H1N1 vaccine, which was previously licensed by Germany. In clinical trials a single dose containing 3.75 mcg of antigen and 0.125 mcg of MF59 adjuvant provoked a strong immune response. The vaccine is cleared for use in people ages 3 years and older. Also, Sanofi said French regulators approved its unadjuvanted H1N1 vaccine. [Nov 13 Novartis press release]

In what may be the first pandemic H1N1 virus detection in North Korea, a man from South Korea got sick with the flu while working across the border at an industrial complex, the Korea Times reported today. The man was diagnosed in South Korea, where the country's unification ministry announced the case today. South Korea reported the case to North Korea and advised it to check all North Korean workers at the industrial complex. [Nov 16 Korea Times story]

Most healthcare workers who have contracted H1N1 influenza were exposed to the flu in their households and community, not in their healthcare institutions, according to testimony Friday before the National Biodefense Science Board (NBSB). The board, chartered by the Department of Health and Human Services, was meeting to discuss mental health, healthcare strain and vaccine supply in the H1N1 pandemic, including how much personal protective equipment health workers require. [Nov 13 NBSB agenda]

The World Health Organization (WHO) today issued an interim guide for mass gatherings during a pandemic. Among risk-assessment points, it urges planners to pay close attention to local virus circulation, length of the event, age of participants, and healthcare capacity. To reduce transmission, advising sick people to stay away from the event is a key task, along with isolating ill people, avoiding travel when sick, and reducing crowding in areas such as dining halls, the WHO said. [WHO guidance]

The Public Health Agency of Canada said yesterday that one dose of adjuvanted H1N1 vaccine is sufficient for healthy children ages 3 through 9 years. The agency called for two doses 21 days apart for children from 6 months through 2 years old and for those 3 through 9 years who have chronic health problems. The recommendations are based on clinical trial findings from Europe. In October, WHO experts suggested one dose is enough for children under 10, but US health officials recommend two doses. [Nov 12 Canadian announcement]

An analysis by Texas health officials finds that the state's Hispanics are being hit disproportionately hard by H1N1 flu, the Houston Chronicle reported. Hispanics make up 37% of the population but accounted for 52% of the 95 H1N1-rlelated deaths through Oct 17. Several risk factors for severe H1N1 disease, including pregnancy, diabetes, and possibly obesity, are more common among Hispanics, said Dr. Joseph McCormick of the University of Texas School of Public Health in Brownsville. [Nov 13 Houston Chronicle report]

France's health ministry said yesterday that a young female healthcare worker was diagnosed with mild Guillain-Barre syndrome (GBS) 6 days after she received a pandemic flu vaccine, Deutsche Presse-Argentur (DPA) reported today. Hers is one of very few cases that have been reported in H1N1 vaccine recipients. The DPA report said 1,700 GBS cases are reported in France each year and that an October poll showed 17% of French respondents planned to get vaccinated against the pandemic virus. [Nov 13 DPA story]

Contrary to most other reports, a study of H1N1 flu cases in Mexico, published in The Lancet, suggests that seasonal flu vaccine may have had a protective effect. Researchers examined data on 69,479 patients who sought treatment for flu-like illness. H1N1 was confirmed in 11% of cases; 56% of those were in people between 10 and 39 years old. Risk of infection was 35% lower in those who had received seasonal flu vaccine (odds ratio, 0.65; 95% confidence interval, 0.55 to 0.77). [Lancet report summary]

A study by the Centers for Disease Control and Prevention (CDC) found no evidence that seasonal flu vaccine was protective against the H1N1 virus. The CDC compared the vaccination coverage among 356 H1N1 case-patients in eight states with the estimated population coverage in those states. Overall vaccine effectiveness was found to be minus-10% but varied widely by age-group. The results, combined with others, suggest that seasonal flu vaccine neither raises nor lowers the risk of H1N1 infection. [Nov 13 MMWR article]

Autopsies of 15 Mexican patients who died of suspected novel H1N1 infections found the virus in 5 of them, of which 4 were young adults, doctors reported in a New England Journal of Medicine letter. Lung tissue was heavier than normal and solid. Four had upper-airway hallmarks seen in seasonal flu cases, but all five had pulmonary damage and interstitial lesions typically seen with H5N1 infections. Two patients showed evidence of other organ involvement seen in lethal H5N1 cases. [Nov 12 N Engl J Med letter]

Tests at Children's Hospital in Philadelphia found that rhinovirus infections, unusually severe with lower-respiratory symptoms, have been responsible for nearly half of flulike illnesses diagnosed at the institution this fall, the Philadelphia Inquirer reported today. The hospital routinely tests for both and saw rhinovirus activity rise before and after the flu season started. Researchers from the CDC are investigating the findings. [Nov 12 Philadelphia Inquirer story]

For the week ending Nov 6, US colleges reported 29 new cases of flulike illness per 10,000 students, a 1% increase from the previous week, the American College Health Association (ACHA) reported today. There were 15 hospitalizations among the 8,951 new flulike illnesses. The ACHA said no deaths have been reported so far and that though the illness pattern seems to be mild so far, it hopes H1N1 vaccine becomes more widely available to blunt the pandemic's impact on students. [ACHA report for week ending Nov 6]

The US Food and Drug Administration (FDA) has approved the use of CSL Biotherapies' 2009 H1N1 flu vaccine in children aged 6 months through 17 years, the company announced yesterday. The injectable vaccine was approved for adults in September. The formulation for children is available in thimerosal-free, single-dose syringes, the company said. [FDA information about CSL vaccine approval]

Chinese and foreign health officials say the aggressive?and widely protested?quarantine measures China has used to fight the H1N1 virus may have helped slow the disease, according to the New York Times. Although cases have mounted recently, China has not yet had a major epidemic. The director of the World Health Organization's Beijing office said China's control measures have worked "very well." The US Embassy said 2,046 Americans had been quarantined in China through October. [Nov 11 New York Times report]

H1N1 vaccine clinics in Ottawa, the Canadian capital, are scheduled to close tomorrow because of a vaccine shortage, CBC News reported yesterday. The city health department said almost 190,000 people, or 22% of the population, would be vaccinated by tonight. Meanwhile, some large medical practices in the United Kingdom were running out of vaccine, as they received the same initial 500-dose allotment as small practices, according to the Pulse, a magazine for British general practitioners. [Nov 11 CBC News report]

GlaxoSmithKline (GSK) said yesterday it received US Food and Drug Administration (FDA) approval of its pandemic H1N1 influenza vaccine. The government has ordered 7.6 million doses of the unadjuvanted vaccine, and plans call for shipping all the doses in December, the company said. The vaccine will be produced in multidose vials at the GSK plant in Quebec. The other four companies providing H1N1 vaccine to the US government received their FDA approvals in September. [Nov 11 GSK news release]

FDA Commissioner Margaret Hamburg, MD, sent a letter to physicians yesterday thanking them for their patience in dealing with pandemic vaccine delays and highlighting the important role they play in preventing serious illnesses and deaths from novel H1N1 flu. The letter describes how the vaccine is made and how officials are monitoring safety. Though most physicians support vaccination, some say they hesitate to get vaccinated themselves or recommend it to patients. [Nov 10 FDA press release]

Canadian doctors today described a case of oseltamivir-resistant pandemic H1N1 flu in a father who underwent prophylaxis then developed flu symptoms after his son was diagnosed with a confirmed infection. In a letter in today's issue of the New England Journal of Medicine, the doctors wrote that their findings support limits for once-a-day postexposure prophylaxis and suggest that patients who develop flu symptoms during prophylaxis immediately start taking the twice-daily treatment dose. [Nov 11 N Engl J Med letter]

A collaboration among Google, the American Lung Association, and the US Department of Health and Human Services has produced a searchable interactive map that displays government and private offices where seasonal and H1N1 vaccines are available, including location and contact details. The tool currently covers chain pharmacies in 50 states and health agencies in 20 states, with more data being added. [Google FluShot]

Canada's military said it would vaccinate Afghan detainees against H1N1 on a case-by-case basis, but none of the suspected Taliban members had yet been vaccinated, the Toronto Star reported today. The plan drew objections from Canada's health minister and from Prime Minister Stephen Harper. Meanwhile, the Miami Herald said the US government shipped 300 vaccine doses to the Navy base at Guantanamo for high-risk personnel such as healthcare workers, but not for prisoners. [Nov 11 Toronto Star report]

Deaths caused by the novel H1N1 flu have doubled in the European Union (EU) in 3 of the past 4 weeks, Bloomberg News reported today. Drawing on data from the European Centre for Disease Prevention and Control, the news agency said the number of deaths per week rose over the past month from 12 to 24 to 49 to 43 and then to 84, with a total of 414 in the EU and European Free Trade Association. [Nov 11 Bloomberg News story]

The US Center for Disease Control and Prevention (CDC) yesterday sent a letter to healthcare providers warning that pneumococcal infections have been seen in some fatal pandemic H1N1 cases and reminding them to offer the pneumonia vaccine to those who are currently recommended to receive them. It urged special emphasis on vaccinating those under age 65 who have high-risk conditions, because coverage rates are especially low and they may be more likely to develop secondary bacterial infections. [Nov 10 CDC letter]

A 14-year-old Virginia boy developed symptoms of Guillain-Barre syndrome (GBS) within 18 hours of getting a pandemic vaccine, MSNBC reported today. His mother had taken him to the health department to receive the seasonal shot, where they also offered the H1N1 vaccine. It's not clear if the boy received both. The CDC said five GBS cases have been reported so far, not including the boy's. It said the rate is less than expected; 80 to 120 cases are reported in the general population each week. [Nov 11 MSNBC story]