Search

This study retrospectively estimated costs for a convenience sample of school-located vaccination (SLV) clinics conducted in Maine during the 2009–2010 influenza season. Surveys were developed to capture the cost of labor including unpaid volunteers as well as supplies and materials used in SLV clinics. Six nurses from different school districts completed a clinic day survey on staff time; four of the six also provided data for materials and supplies. For all clinics, average per-dose labor cost was estimated at $5.95. Average per-dose material cost, excluding vaccine, was $5.76. From the four complete clinic survey responses, total per-dose cost was estimated to be an average of $13.51 (range = $4.91–$32.39). Use of donated materials and uncompensated volunteer staff could substantially reduce per-dose cost. Average per-dose cost could also be lowered by increasing the number of doses administered in a clinic.

The hemato-oncology community has been seriously concerned about the H1N1 pandemic of 2009. Here, we report on the evaluation of the immunogenicity and tolerability of H1N1v monovalent vaccines in young patients with cancer during this pandemic.Between December 7, 2009 and February 26, 2010, 20 children receiving chemotherapy for solid tumors at the Institute of Hematology and Pediatric Oncology of Lyon, were immunized by 2 doses of either AS03-adjuvanted or nonadjuvanted vaccine. The level of specific antibodies was assessed at D21 and D42.Seroconversion was observed in 13 of the 20 cases (65%), and 18 of 20 cases (90%) had protective titers after the 2 doses. Exploratory univariate analysis failed to show a significant influence of prevaccination lymphocyte counts on seroresponse rates.These data suggest that H1N1v monovalent vaccines were well tolerated by young cancer patients while on chemotherapy and achieved protective immune response in most cases.

Objective: To describe the epidemiological characteristics of the 2009 H1N1 pandemic virus (pH1N1) over the 2009 and 2010 influenza seasons in Australia and New Zealand (NZ) and compare them with expectations based on previous pandemics. Methods: Laboratory-confirmed influenza and influenza-like illness (ILI) data were collected from established general practitioner sentinel surveillance schemes in NZ, Victoria and Western Australia (WA) throughout the 2009 and 2010 winter influenza seasons. Respiratory swabs from a sample of ILI patients were tested for influenza type and subtype. ILI rates and laboratory-confirmed influenza data were analysed by age group and over time. Morbidity, mortality and reproductive number data were collated from the published literature. Results: Peak ILI rates and the percentage of influenza-positive swabs from ILI patients from all sentinel surveillance schemes were considerably lower in 2010 than 2009. Compared to the population, cases of ILI were over-represented in the young. While the age distributions in NZ and WA remained consistent, ILI cases were significantly younger in Victoria in 2009 compared to 2010. In Victoria, laboratory-confirmed pH1N1 comprised up to 97% of influenza-positive swabs in 2009 but only 56–87% in 2010. Mortality and hospitalisations were lower in 2010. The effective reproduction number (R) for pH1N1 was estimated to be 1.2–1.5 in NZ and WA, similar to estimated R values for seasonal influenza. Data from the surveillance systems indicated differences in the epidemiology of pH1N1 compared to expectations based on previous pandemics. In particular, there was no evidence of a second pandemic wave associated with increased mortality, and complete influenza strain replacement did not occur. Implications: Pandemic planning needs to accommodate the potential for influenza viruses to produce pandemics of various infectiousness and degrees of severity.

Objective: This study assessed the immunogenicity, long-term persistence of immune response and safety of a single dose of an A/California/07/2009 H1N1 pandemic influenza vaccine adjuvanted with AS03 (α-tocopherol and squalene based oil-in-water emulsion Adjuvant System) in subjects ≥ 65 y of age (NCT01114620). Results: At Day 21, the HI immune response met all three European guidance criteria [seroconversion rate (SCR): 60.0%; seroprotection rate (SPR): 64.0%; geometric mean fold rise (GMFR): 10.2] and the US guidance criterion for SCR. At month 6, the HI immune response against the A/California/07/2009 H1N1 strain persisted but at levels lower than that observed at Day 21 (SCR: 38.8%; SPR: 42.9%; HI antibody geometric mean titer: 27.6); the European regulatory guidance criteria for SCR and GMFR were still met. Overall, the vaccine was well-tolerated. Conclusion A single dose of the 3.75µg HA AS03-adjuvanted H1N1 2009 pandemic vaccine induced immune responses against the vaccine strain that met the European regulatory guidance criteria at day 21 in the elderly Japanese population; the immune response persisted at lower levels at month 6. No safety concerns were identified. These results suggest that two vaccine doses might be useful for the elderly population to improve antibody induction and persistence. Methods: In this open-label, single group study, 50 subjects received one dose of the 3.75 µg hemagglutinin (HA) AS03-adjuvanted H1N1 2009 vaccine. Immunogenicity assessments were made before vaccination, 21 days and six months after vaccination using hemagglutination inhibition (HI) and microneutralization assays. Immunogenicity end points were based on US and European regulatory criteria.

Purpose The 2009 worldwide influenza A/H1N1 pandemic particularly affected younger people, including schoolchildren. We assessed the effects of class/school closure during the pandemic on the spread of H1N1 infection in Japan. Methods We prospectively monitored 2,141 schoolchildren in 57 classes at two elementary schools and two junior high schools in Japan, and evaluated the effects of class/school closures on the spread of H1N1 using descriptive epidemiological methods. Results The cumulative rate of H1N1 infection among these children was 40.9 % (876 children). There was a total of 53 closures of 40 classes, including school closures, during the pandemic. Time-course changes in the epidemic curve showed that school closure reduced the following epidemic peak more than class closure. A Poisson regression model showed that a longer duration of closure was significantly related to decreased H1N1 occurrence after the resumption of classes. Conclusions School closure more effectively inhibits subsequent epidemic outbreaks than class closure. Longer school closures are effective in reducing the spread of infection, and school closure should be implemented as early as possible., Article, INFECTION. 40(5):549-556 (2012)

were collected and tested by RT-PCR of which 22.7% (487) were confirmed A(H1N1)pdm09; H3N2, H1N1, and B were positive in 2.2%, 1.1%, and 7.2%, respectively. The highest rate of A(H1N1)pdm09 cases (57.4%) was detected in the 6-20 year-old age group. Importantly, Bhutan increased from 3 sentinel sites in April 2009 to 11 a year later, and in April 2010 established PCR capability for influenza. Conclusions Despite relative isolation, the A(H1N1)pdm09 reached Bhutan within 3 months of identification in Mexico. The H1N1 pandemic has made Bhutan more prepared for epidemics in the future.

Background Acute respiratory insufficiency characterised critically ill patients during the influenza A (H1N1) pandemic 20092010. Detailed understanding of disease progression and outcome in relati ...

Influenza represents a substantial global healthcare burden, with annual epidemics resulting in 3–5 million cases of severe illness with a significant associated mortality. In addition, the risk of a virulent and lethal influenza pandemic has generated widespread and warranted concern. Currently licensed influenza vaccines are limited in their ability to induce efficacious and long-lasting herd immunity. In addition, and as evidenced by the H1N1 pandemic in 2009, there can be a significant delay between the emergence of a pandemic influenza and an effective, antibody-inducing vaccine. There is, therefore, a continued need for new, efficacious vaccines conferring cross-clade protection—obviating the need for biannual reformulation of seasonal influenza vaccines. Development of such a vaccine would yield enormous health benefits to society and also greatly reduce the associated global healthcare burden. There are a number of alternative influenza vaccine technologies being assessed both preclinically and clinically. In this review we discuss viral vectored vaccines, either recombinant live-attenuated or replication-deficient viruses, which are current lead candidates for inducing efficacious and long-lasting immunity toward influenza viruses. These alternate influenza vaccines offer real promise to deliver viable alternatives to currently deployed vaccines and more importantly may confer long-lasting and universal protection against influenza viral infection.

School nurses played a key role in Maine's school-located influenza vaccination (SLV) clinics during the 2009-2010 pandemic season. The objective of this study was to determine, from the school district perspective, the labor hours and costs associated with outside-clinic coordination activities (OCA). The authors defined OCA as labor hours spent by staff outside of clinic operations. The authors surveyed a convenience sample of 10 school nurses from nine school districts. Eight nurses responded to the survey, representing seven districts, 45 schools and 84 SLV clinics that provided a total of 22,596 vaccine doses (H1N1 and seasonal combined) to children and adolescents. The mean total OCA time per clinic was 69 hours: out of total hours, 22 (36%) were spent outside regular clinic operation time. The authors estimated the mean cost of OCA to be $15.36 per dose. Survey respondents reported that costs would be lower during non-pandemic seasons and as schools become more proficient at planning clinics.

Please cite this paper as: Greene et al. (2012) Patterns in influenza antiviral medication use before and during the 2009 H1N1 pandemic, Vaccine Safety Datalink Project, 2000-2010. Influenza and Other Respiratory Viruses 6(601), e143–e151. Background U.S. recommendations for using influenza antiviral medications changed in response to viral resistance (to reduce adamantane use) and during the 2009 H1N1 pandemic (to focus on protecting high-risk patients). Little information is available on clinician adherence to these recommendations. We characterized population-based outpatient antiviral medication usage, including diagnosis and testing practices, before and during the pandemic. Methods Eight medical care organizations in the Vaccine Safety Datalink Project provided data on influenza antiviral medication dispensings from January 2000 through June 2010. Dispensing rates were explored in relation to changes in recommendations and influenza diagnosis and laboratory testing frequencies. Factors associated with oseltamivir dispensings in pandemic versus pre-pandemic periods were identified using multivariable logistic regression. Results Antiviral use changed coincident with recommendations to avoid adamantanes in 2006, to use alternatives to oseltamivir in 2008, and to use oseltamivir during the pandemic. Of 38,019 oseltamivir dispensings during the pandemic, 31% were to patients not assigned an influenza diagnosis, and 97% were to patients not tested for influenza. Oseltamivir was more likely to be dispensed in pandemic versus pre-pandemic periods to patients

The influenza A/H1N1 pandemic in 2009 created an urgent need to develop vaccines for mass immunization. To guide decisions regarding the optimal immunization dosage and schedule for adults, we evaluated two monovalent, inactivated, unadjuvanted H1N1 influenza vaccines in independent, but simultaneously conducted, multi-center Phase 2 trials of identical design.Healthy adults, stratified by age (18-64 years and ≥65 years), were randomized (1:1 allocation), in a double-blind, parallel-group design, to receive two intramuscular doses (21 days apart) of vaccine containing approximately 15 μg or 30 μg of hemagglutinin (HA). Primary endpoints were safety (reactogenicity for 8 days after each vaccination and vaccine-associated serious adverse events during the 7 month study) and immunogenicity (proportion of subjects, stratified by age, achieving a serum hemagglutination inhibition [HI] antibody titer ≥1:40 or a ≥4-fold rise in titer after a single injection of either dosage).Both vaccines were well-tolerated. A single 15 μg dose induced HI titers ≥1:40 in 90% of younger adults (95% confidence interval [CI] 82-95%) and 81% of elderly (95% CI 71-88%) who received Sanofi-Pasteur vaccine (subsequently found to contain 24 μg HA in the standard potency assay), and in 80% of younger adults (95% CI 71-88%) and 60% of elderly (95% CI 50-70%) who received CSL vaccine. Both vaccines were significantly more immunogenic in younger compared with elderly adults by at least one endpoint measure. Increasing the dose to 30 μg raised the frequency of HI titers ≥1:40 in the elderly by approximately 10%. Higher dosage did not significantly enhance immunogenicity in younger adults and a second dose provided little additional benefit to either age group.These trials provided evidence for policymakers that a single 15 μg dose of 2009 A/H1N1 vaccine would likely protect most U.S. adults and suggest a potential benefit of a 30 μg dose for the elderly.

We investigate dynamics of public perceptions of the 2009 H1N1 influenza pandemic to understand changing patterns of sense-making and blame regarding the outbreak of emerging infectious diseases. We draw on social representation theory combined with a dramaturgical perspective to identify changes in how various collectives are depicted over the course of the pandemic, according to three roles: heroes, villains and victims. Quantitative results based on content analysis of three cross-sectional waves of interviews show a shift from mentions of distant collectives (e.g., far-flung countries) at Wave 1 to local collectives (e.g., risk groups) as the pandemic became of more immediate concern (Wave 2) and declined (Wave 3). Semi-automated content analysis of media coverage shows similar results. Thematic analyses of the discourse associated with collectives revealed that many were consistently perceived as heroes, villains and victims.

Screening delayed spread by, Pandemic influenza A (H1N1) 2009 virus spread rapidly around the world in 2009. We used multiple data sources from surveillance systems and specific investigations to characterize the transmission patterns of this virus in China during May–November 2009 and analyze the effectiveness of border entry screening and holiday-related school closures on transmission. In China, age distribution and transmission dynamic characteristics were similar to those in Northern Hemisphere temperate countries. The epidemic was focused in children, with an effective reproduction number of ≈1.2–1.3. The 8 days of national holidays in October reduced the effective reproduction number by 37% (95% credible interval 28%–45%) and increased underreporting by ≈20%–30%. Border entry screening detected at most 37% of international travel–related cases, with most (89%) persons identified as having fever at time of entry. These findings suggest that border entry screening was unlikely to have delayed spread in China by >4 days.

Objective: To investigate the impact of excluding cases with alternative diagnoses on the sensitivity and specificity of the Centers for Disease Control and Prevention’s (CDC) influenza-like illness (ILI) case definition in detecting the 2009 H1N1 influenza, using Geographic Utilization of Artificial Intelligence in Real-Time for Disease Identification and Alert Notification, a disease surveillance system.Design: Retrospective cross-sectional study design.Setting: Emergency department of an urban tertiary care academic medical center.Patients: 1,233 ED cases, which were tested for respiratory viruses from September 5, 2009 to May 5, 2010.Main Outcome Measure: The main outcome measures were positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of the ILI case definition (both including and excluding alternative diagnoses) to detect H1N1.Results: There was a significant decrease in sensitivity (χ2 = 9.09, p 0.001) and significant improvement in specificity (χ2 = 179, p 0.001), after excluding cases with alternative diagnoses.Conclusion: When early detection of an influenza epidemic is of prime importance, pursuing alternative diagnoses as part of CDC’s ILI case definition may not be warranted for public health reporting due to the significant decrease in sensitivity, in addition to the resources required for detecting these alternative diagnoses.

Background The rapid influenza antigen test (RIAT) has been questioned because of its poor sensitivity. Clinicians are confused as to what diagnostic help it may provide. RIAT was reappraised by other laboratory confirmatory tests for its diagnostic capacity. Methods Records of RIAT, RT-PCR and virus culture, performed for upper respiratory tract samples during the period from July 2009 to January 2010, were reviewed. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of RIAT were evaluated with RT-PCR and virus culture as reference. Results With either positive RT-PCR or positive virus culture as confirmation of presence of the virus, the overall sensitivity was 44.2% (235/532) and the overall PPV was 91.1% (235/258). With both negative RT-PCR and negative virus culture as confirmation of absence of the virus, the overall specificity was 98.2% (239/264) and the overall NPV was 92.6% (239/258). The PPV reached 96.2% during peak prevalence of infection and the NPV increased to 91.7% with low prevalence. The sensitivity for seasonal H3N2 was 56% (56/100), significantly better than the 39.6%, (156/394) for 2009 pandemic H1N1. Although RIAT positivity correlated to the viral load in samples, a substantial amount of negative RIAT samples had high viral load, with 16.8% (260/1548) of Ct value less than 36 and 8.8% (136/1548) of Ct value less than 31. Conclusion An algorithm is derived for the fast and inexpensive point-of-care laboratory test RIAT for appropriate application in clinical diagnosis of influenza virus infection. In peak seasons, positive RIAT confirms the diagnosis, with PPV over 96%. In low seasons, negative RIAT sufficiently excludes the diagnosis, with NPV over 91%. The sensitivity of RIAT may vary with different species of the influenza virus. Negative RIAT is not necessarily equal to low viral load in the upper respiratory tract or low infectivity of the patient.

This study analyzes US and South Korean news coverage of the H1N1 pandemic to examine cross-cultural variations in attention cycle patterns, cited sources, and news frames. A content analysis was conducted on 630 articles from US and Korean newspapers during the period of April to October 2009. It found that attention cycle patterns, news frames, and sources varied across the two countries according to professional norms, cultural values, social ideologies, and occurrences of relevant events. While US news coverage showed two phases of waxing and waning attention, Korean news coverage showed five phases. The frames used in US news stories placed more emphasis on attribution of responsibility, action, and reassurance. Other framing variations were found as news attention in each country rose and fell. Regarding sources used, Korean news stories relied more on governmental sources, while US news stories used a greater diversity of sources. This study advances research on variations in the attention cycle fo...

Existed evidences show that airborne transmission of human respiratory droplets may be related with the spread of some infectious disease, such as severe acute respiratory syndrome (SARS) and H1N1 pandemic. Non-pharmaceutical approaches, including ventilation system and personal protection, are believed to have certain positive effects on the reduction of co-occupant's inhalation. This work then aims to numerically study the performances of mouth covering on co-occupant's exposure under mixing ventilation (MV), under-floor air distribution (UFAD) and displacement ventilation (DV) system, using drift-flux model. Desk partition, as one generally employed arrangement in plan office, is also investigated under MV. The dispersion of 1, 5 and 10 μm droplet residuals are numerically calculated and CO2 is used to represent tracer gas. The results show that using mouth covering by the infected person can reduce the co-occupant's inhalation greatly by interrupting direct spread of the expelled droplets, and best performance can be achieved under DV since the coughed air is mainly confined in the microenvironment of the infected person. The researches under MV show that the two interventions, mouth covering and desk partition, achieve almost the same inhalation for fine droplets while the inhalation of the co-occupant is lower when using mouth covering for large droplets.

Objective This article aimed to assess the impact on quality and cost of care of using a tent in the emergency department (ED) parking lot to screen patients with an influenza-like illness (ILI). Methods A nurse-driven protocol was used to triage and perform a medical screening examination for patients with ILI who could be safely discharged from the tent. A before-after study design was used to assess the intervention, focusing on the immediate pre-tent and tent periods, when the average daily census exceeded 250 visits (67% above our historic baseline). We compared quality and cost data on patients treated for ILI before and while the tent was in operation. Results During the pre-tent and tent periods, 5809 and 5864 encounters, respectively, were recorded in the ED; elopement rates were 12.9% and 1.8% of patients, respectively. Of the 1141 patients screened in the tent, 838 were triaged out. Average ED turnaround time for all patients was 282 and 152 minutes, with an overall rate of ED recidivism of 5.03% and 5.36% (1.8% for ILI-related revisit for tent patients) during the pre-tent and tent periods, respectively. The average cost of screening was $30.45 per patient. The incremental cost-effectiveness ratio, representing the additional cost to decrease the elopement rate by 1%, was $697.30, with the tent being the dominant strategy. Conclusions The tent provided cost-effective care with measurable improvements in quality of care indicators. Our analytic model demonstrated that the incremental cost-effectiveness ratio of tent during the H1N1 surge was modest. The tent may be a useful model during future pandemics.

Please cite this paper as: Balasegaram et al. (2012) Patterns of early transmission of pandemic influenza in London – link with deprivation. Influenza and Other Respiratory Viruses 6(3), e35–e41. Background During the early containment phase in England from April to June 2009, the national strategy for H1N1 pandemic influenza involved case investigation and treatment, and tracing and prophylaxis of contacts. Objective To describe the relationship between early transmission of H1N1 pandemic influenza in London and age and socio-economic status. Methods Epidemiological data on cases of pandemic flu in London reported to the London Flu Response Centre were analysed to determine patterns of transmission. Results There were 3487 reported cases (2202 confirmed, 1272 presumed and 14 probable) from 20 April to 28 June 2009, during the ‘containment’ period. The highest report rate of 206 per 100 000 (95% CI 195–218) was seen in primary school–age children (5−11 years) followed by 129 (95% CI 119–139) in secondary school–age children (12–18 years). Reports of cases were initially concentrated in affluent areas but overall showed a clear trend with deprivation and risk ratio of 2·32 (95% CI 1·94–2·78) between the most deprived and the least deprived. Conclusion Early transmissions were highest amongst school-aged children but linked with socio-economic deprivation across all age groups.

Objectives. We assessed the impact of social determinants of potential exposure to H1N1—which are unequally distributed by race/ethnicity in the United States—on incidence of influenza-like illness (ILI) during the 2009 H1N1 pandemic. Methods. In January 2010 we surveyed a nationally representative sample (n = 2079) of US adults from the Knowledge Networks online research panel, with Hispanic and African American oversamples. The completion rate was 56%. Results. Path analysis examining ILI incidence, race, and social determinants of potential exposure to H1N1 demonstrated that higher ILI incidence was related to workplace policies, such as lack of access to sick leave, and structural factors, such as number of children in the household. Hispanic ethnicity was related to a greater risk of ILI attributable to these social determinants, even after we controlled for income and education. Conclusions. The absence of certain workplace policies, such as paid sick leave, confers a population-attributable risk of 5 million additional cases of ILI in the general population and 1.2 million cases among Hispanics. Federal mandates for sick leave could have significant health impacts by reducing morbidity from ILI, especially in Hispanics.

H1N1 has contributed to a significant number of fatalities in Malaysia. This study investigated the behaviour response and attitude of educated young adults towards their health. This study was conducted in the suburban territory. Hypothesis testing was completed using Chi-square and Fisher Exact test for categorical data to compare the differences in proportion. This study concluded that health seeking behaviour and behaviour changes among educated young adults in Malaysia should be improved. There was no strong predictor to indicate that difference in education background will grant positive difference in health seeking behaviour and behaviour changes with regard to H1N1 pandemic.

The 2009 influenza A/H1N1 pandemic caused an increase in complications in pregnant women. To be well prepared for a next pandemic, we investigated the obstetric and maternal complications of this pandemic. In our national cohort of 59 pregnant women who were admitted to the hospital, no major complications apart from preterm birth and admission to the neonatal intensive care unit were observed. Although the small size of this study precludes us drawing any definitive conclusions, comparing our results with those in other countries suggests that the influenza A/H1N1 pandemic had a relatively benign course in pregnant women in The Netherlands.

Please cite this paper as: Kim et al. (2012) Is abdominal obesity associated with the 2009 influenza A (H1N1) pandemic in Korean school-aged children? Influenza and Other Respiratory Viruses 6(5), 313–317. Objective Given their medical vulnerabilities, we investigated the epidemiological factors related to H1N1 infection in school-aged children. Methods This study analyzed data collected on 7448 school-aged children in South Korea between 18 November and 8 December 2009. Results We found that H1N1 infection was associated with body mass index (BMI), waist circumference (WC), the use of facemasks, contact history with H1N1-infected persons, and overseas travel history (P

Analysis of a US hospitalization database demonstrated that more influenza patients were hospitalized and the age distribution of hospitalizations was younger during the 2009 (H1N1) influenza A pandemic compared with the three previous influenza seasons. The duration of hospital stay remained stable in all four seasons. A higher proportion of patients was treated with antivirals (P < 0·0001), comprised almost entirely of neuraminidase inhibitors, and the proportion was highest in those with influenza confirmed by diagnostic testing (P < 0·0001). Approximately one-third remained untreated. Young children had the lowest rate of neuraminidase-inhibitor treatment during the 2009 pandemic (P < 0·05).

Background: Adequate pandemic preparedness is imperative for home health agencies. Methods: A 23-item pandemic preparedness survey was administered to home health agencies in the spring of 2010. The KruskalWallis (KW) test was used to evaluate the relationships between agency size and preparedness indicators. Significant findings were further analyzed by the Mann-Whitney (MW) U post hoc test. Results: The response rate was 25% (526/2,119). Approximately one-third of respondents (30.4%; n 5 131) reported experiencing trouble obtaining supplies during the 2009 H1N1 pandemic. Small agencies were significantly more likely (Krusal-Wallis [KW] 5 9.2; P , .01) to report having trouble obtaining supplies than larger-sized agencies (Mann-Whitney [MW] 5 14,080; P , .01). Most home health agencies (87.3%; n 5 459) reported having a pandemic influenza plan. One-third (33.5%; n 5 176) reported having no surge capacity; only 27.0% (n 5 142) reported having at least a 20% surge capacity. The largest agencies were significantly more likely (KW 5 138; P , .001) to report having at least 20% surge capacity than medium-sized agencies (MW 5 7,812; P 5 .001) or small agencies (MW 5 8,306; P , .001). Approximately 80% (n 5 414) reported stockpiling personal protective equipment. Three-quarters (71.3%; n 5 375) reported fit-testing staff, and half (49.2%; n 5 259) reported participating in disaster drills. The majority of home health professionals (75.1%; n 5 395) reported having a personal/family disaster plan in place. Conclusion: There are gaps in US home health agency pandemic preparedness, including surge capacity and participation in disaster drills, that need to be addressed.

Summary Objective To assess the preparedness of a multispeciality teaching hospital in India in tackling the swine flu pandemic. Study design Evaluation study. Methods This cross-sectional observational study was done among paramedical staff, MBBS students and resident doctors of Government Medical College and Hospital Chandigarh (GMCH), India. Results Of the subjects selected for the study, awareness about causal agent was 89.2%. All the participants were aware of the strain of virus and 96.3% knew about its transmission by droplet method. About 1/3rd of respondents had knowledge of its infectivity. Preparedness was good (93.3%)in all aspects except for the diagnostics. Conclusions The Institute (GMCH) was well prepared for managing the swine Flu.

A diverse set of national and international bodies is increasingly commenting upon other organizations� compliance with �global administrative law� norms, creating a complex network of interaction and review. Although many forms of interaction can be identified and observed, horizontal review between international organizations appears to be relatively rare. This article examines one instance in which review did emerge: the Parliamentary Assembly of the Council of Europe's criticisms of the transparency and accountability of the World Health Organization (WHO) during the H1N1 pandemic. Two key questions arise from the case study. First, what structural or institutional features allowed inter-institutional review to take place? And, secondly, why would two institutions have such divergent views of an international organization's accountability and transparency? The analysis suggests that a key factor in allowing horizontal review to occur is diversity in institutional composition � in terms either of membership, distribution of power between members, or interests represented by members. In this case study, the Parliamentary Assembly represented the interests of states� legislative branches, whereas the WHO representatives reflect the interests of states� executive branches. Variations in baseline assumptions regarding the WHO's function in regulating infectious disease response and to whom it should be accountable may partially explain the substantive divergence of opinion.

Ethical issues are present at each stage in the vaccine product life cycle, the period extending from the earliest stages of research through the eventual design and implementation of global vaccination programs. Recent developments highlight fundamental principles of vaccine ethics and raise unique issues for ongoing vaccination activities worldwide. These include the 2009-10 H1N1 pandemic influenza vaccination campaign, renewed attention to the potential global eradication of polio, and the ongoing evaluation of vaccine risk controversies, most notably the alleged link between childhood vaccines and autism. These cases present ethical challenges for public health policy-makers, scientists, physicians, and other stakeholders in their efforts to improve the health of individuals, communities, and nations through vaccination.

Through a quantitative content analysis, this study reveals how 13 organizations differently framed the 2009 H1N1 flu pandemic crisis via their traditional ( n = 211) and social media ( n = 534) responses. When framing the crisis as a disaster, a health crisis, or a general health issue organizations relied more on traditional than social media. However, they tended to use social media as much as traditional media when framing the pandemic as a general crisis. In addition, organizations relied more on traditional media to address emotions than on social media. Together, the study's findings provide applied and theoretical insights for scholars and crisis managers.

In the fall of 2009, our hospital introduced a surveillance system to monitor the increase in cases of H1N1 pandemic influenza A virus infection. The system involved tracking cases of influenza-like illness in the emergency department, the outpatient clinics, and the inpatient wards as well as specimens with positive polymerase chain reaction results reported by the microbiology laboratory. Our data correlated well with national and regional data.

We present here a detailed analysis of anaphylaxis cases reported to GlaxoSmithKline safety database following vaccination with its H1N1 pandemic influenza vaccines, Pandemrix™ and Arepanrix™. Cases were assessed according to the Brighton Collaboration Case Definition (BCCD) as either confirmed diagnosis (97/395, 24.6%), insufficient information to fulfil the minimal criteria of the case definition (117/395, 29.6%) or anaphylaxis excluded (181/395, 45.8%). There was no evidence that the rate of anaphylaxis following vaccination with Pandemrix™ or Arepanrix™ is increased with respect to the rates of anaphylaxis for other vaccines. Our analysis also highlighted the challenges of reliably determining the rate of anaphylaxis as an adverse event in the postmarketing setting following mass vaccination, as anaphylaxis was excluded in 45.8% of reported cases.

Patients with hematologic malignancies are at increased risk of influenza and its complications. Despite current health recommendations and evidence favoring influenza vaccination, vaccination rates remain low in cancer patients.The purpose of this study was to determine which factors influenced vaccination rates.During the 2009-2010 pandemic H1N1 and seasonal influenza season, we surveyed patients with hematologic malignancies in a Canadian cancer center. Of the patients participating in our study (n = 129), 66% and 57% received the H1N1 pandemic influenza and seasonal influenza vaccines, respectively.A number of reasons for vaccination refusal were reported, most relating to general skepticism about the safety and efficacy of vaccination. Physician advice was also a factor influencing vaccination rates in patients. The vaccination rate for seasonal influenza was 39% in patients65 years old, significantly lower than the rate of 73% reported for patients agedor = 65 years (P0.0001).Future education programs should target younger patient populations and health-care workers, focusing on vaccine safety and efficacy in the high-risk cancer population.

Introduction The aim of this study was to highlight the perceived risks, behavioural changes and the rate of acceptance of seasonal and pandemic (H1N1) 2009 influenza vaccines by healthcare workers (HCWs) in a French Teaching Hospital. Methods We sampled HCWs from the Angers French Teaching Hospital (France) using a cross-sectional intercept design during phase 5A of the 2009 French National Plan for the Prevention and Control of ‘Pandemic Influenza’. From November 2009 to February 2010, HCWs were approached in the workplace to undertake the survey. The primary endpoint assessed immunization coverage among HCWs who had contact with at-risk-patients. Results Of the 532 HCWs who answered the questionnaire, 119 (22.4%) had received a seasonal vaccine and 194 (36.5%) the H1N1 pandemic vaccine. Coverage rate was significantly higher among physicians (45% for the seasonal vaccine, 61% for the H1N1 vaccine). The main reasons given for acceptance of the seasonal vaccine were “protection of the patient” and “self-protection”, whereas the main arguments against were “low risk of being infected” and “doubts about vaccine safety”. For the H1N1 vaccine, reasons for vaccination were to “protect the patient” and “protect the family”. The main arguments against were “fear of side effects” and “doubts about vaccine safety”. Conclusion This study emphasizes the lack of perception by HCWs of the importance of being immunized against seasonal and pandemic A (H1N1) 2009 Influenza. In the future, particular efforts are needed, during vaccination campaigns, to provide more information to HCWs regarding development process and safety of such vaccines.

In May 2011, the World Health Assembly will receive the report of its International Health Regulations Review Committee examining responses to the outbreak of the 2009 H1N1 pandemic influenza and identifying lessons to be learnt. This will emphasise the need for better risk communication in future. But risk and communication are not objective facts; they are socially mediated cultural products. Responses to crises are not only simply determined by the situation at hand, but also through mental models developed over protracted periods. Accordingly, those responsible for advocating the precautionary approach and encouraging the securitisation of health, that both helped encourage a catastrophist outlook in this instance, are unlikely to be held to account. These elite confusions have come at an enormous cost to society.

At the beginning of the swine influenza (H1N1) pandemic in the spring of 2009, there were still stories of human seasonal influenza A circulating in the New York area. Adult patients admitted with influenza-like illnesses (ILIs) (fever > 102°F, dry cough, and myalgias) presented diagnostic problems. First, clinicians had to differentiate ILIs from influenza, and then differentiate human seasonal influenza A from H1N1 in hospitalized adults with ILIs and negative chest films (no focal segmental/lobar infiltrates). Human seasonal influenza A was diagnosed by rapid influenza diagnostic tests (RIDTs), but H1N1 was often RIDT negative. Reverse transcriptase-polymerase chain reaction for H1N1 was restricted or not available. The Winthrop-University Hospital Infectious Disease Division developed clinical diagnostic criteria (a diagnostic weighted point score system) to rapidly and clinically diagnose H1N1 in patients with negative RIDTs. The point score system was modified and shortened for ease of use, that is, the diagnostic H1N1 triad (any 3 of 4) (ILI, see above) plus thrombocytopenia, relative lymphopenia, elevated serum transaminases, or an elevated creatine phosphokinase. Our clinical experience during the pandemic allowed us to develop the swine diagnostic H1N1 triad. In the process, similarities and differences between human seasonal influenza A and H1N1 were noted. We present 2 illustrative cases of severe influenza, one due to human seasonal influenza A and one due to H1N1, for clinical consideration reflective of our experiences early in the H1N1 pandemic in 2009.

Influenza A virus is a particularly problematic virus because of its ability to cause high levels of morbidity on a global scale within a remarkably short period of time. It also has the potential to kill very large numbers of people as occurred in the Spanish influenza pandemic in 1918. Options for antiviral therapy are limited because of the paucity of available drugs and the rapid mutation rate of the virus leading to the emergence of drug-resistant strains. The current H1N1 pandemic and potential threats posed by other strains highlight the need to develop novel therapeutic and prophylactic strategies. Here, we summarize the current state and recent developments of peptide-based inhibitors of influenza A virus.

Of those patients hospitalized in the United States during the 2009 H1N1 influenza pandemic, approximately one-third were under the age of 18 yr (1). The attributed mortality was relatively higher among young children, pregnant women, and individuals with immunosuppression, severe obesity, and other comorbidities when compared to seasonal influenza (2, 3). The virologic and immunologic mechanisms accounting for differences in clinical manifestations and disease outcomes between 2009 H1N1 and seasonal influenza A infections have not yet been fully elucidated. In addition, emerging resistance of the 2009 H1N1 virus to oseltamivir, a NA inhibitor and the mainstay of treatment, has led to pulmonary complications, severe disease, and poor outcomes especially among immunocompromised individuals (4, 5). We report a case of an immunosuppressed pediatric renal transplant patient with mild pneumonia caused by oseltamivir-resistant 2009 H1N1 influenza and successfully treated with zanamivir. This case highlights the complex interplay between pathogen and host, underscores the possible importance of the innate immune system in influenza, and raises questions regarding viral fitness and resistance.

SUMMARYThe A(H1N1) influenza pandemic has been a challenge for public health surveillance systems in all countries. An objective evaluation has not been conducted, as yet, of the performance of those systems during the pandemic. This paper presents an algorithm based on Benford's Law and the mortality ratio in order to evaluate the quality of the data and the sensitivity of surveillance systems. It analyses records of confirmed cases reported to the Pan American Health Organization by its 35 member countries between epidemiological weeks 13 and 47 in 2009. Seventeen countries did not fulfil Benford's Law, and mortality exceeded the regional average in 40% of the countries. The results suggest uneven performance by surveillance systems in the different countries, with the most frequent problem being low diagnostic coverage. Benford's Law proved to be a useful tool for the evaluation of a public health surveillance system's performance.

Asthma seems to be the more prevalent underlying condition in patients hospitalized for H1N1-related flu.A prospective survey was conducted during the early phase of H1N1 pandemic in France in asthmatic children before vaccination to assess whether severe exacerbations in childhood asthma are associated with influenza-like illness (ILI, the definition of H1N1-related flu in a pandemic). Eight pediatricians in primary care distributed in three localities (Paris, south suburb, and west suburb) conducted the survey (4 weeks/locality from week 36 to 47). At each visit, the pediatrician filled a questionnaire entering the information regarding asthma treatment, severe exacerbation (at least 3 days' use of systemic corticosteroids), and ILI (temperature ≥37.8°C, cough, and/or sore throat, in the absence of a known cause other than influenza) during the past 3 weeks.The survey included 1155 asthmatic children (mean age [SD]: 7.5 years [4.1]); almost all visits were scheduled (99%). A severe exacerbation was recorded in 121 children [10.5%; 95% confidence interval (CI): 8.7-12.2%], which was concomitant with ILI in 20 children (16.5%; 95% CI: 9.9-23.2%), whereas 1034 children did not exhibit any exacerbation. In these latter children, 40 ILI were observed (3.9%; 95% CI: 2.7-5.0%), which constituted a significantly lesser percentage as compared with children with both exacerbation and ILI (p.0001). This result remained significant in each locality. Overall, 60/1155 (5.2%; 95% CI: 3.9-6.5%) asthmatic children had an ILI.Our survey shows that severe exacerbation and ILI are strongly associated during the H1N1 pandemic in asthmatic children.

SUMMARYNon-pharmaceutical interventions (NPI) such as facemasks and intensified hand hygiene may be effective in preventing influenza infections in households. It may be equally important that household members, especially children, can learn to use, maintain and tolerate these measures. We monitored adherence and tolerability of these NPI within a cluster-randomized trial in households with influenza index patients. We recruited 147 participants in 41 households, 39 (95%) out of 41 index patients were children (aged

Address correspondence to: Angela K. Shen, MPH, National Vaccine Program Office, Department of Health and Human Services, 200 Independence Ave. SW, 717H, Washington, DC 20201-0004; tel. 202-690-5566; fax 202-690-4631; e-mail . The National Vaccine Advisory Committee (NVAC) is a federal advisory committee that provides vaccine and immunization policy recommendations to the U.S. Department of Health and Human Services (HHS). The NVAC’s diversity of professional and stakeholder perspectives enables the committee to play a role in strengthening the U.S. vaccine and immunization system, as well as inform vaccine policy. This article details the NVAC’s contribution, focusing on its recent response to the 2009 H1N1 pandemic, and reveals opportunities for the NVAC to further shape this public health sector in the future.

Objective: The 2009 H1N1 pandemic reinforced the need for a planned response to increased demand for critical care. Triage protocols have been proposed incorporating the exclusion of specified subgroups of patients from critical care. There have been no studies that explore the theoretical underpinning of triage at referral, and it is not clear under what circumstances triage would confer the intended benefits. We sought to explore the mechanisms whereby triage could lead to fewer deaths across a critical care population in the context of a pandemic.Design: We constructed a mathematical model based on queuing theory to compare the estimated short-term survival achieved by using a critical care service with and without triage at referral. Illustrative scenarios concerning a hypothetical critical care population were constructed to explore the roles of length of stay and critical care survival in determining the impact of triage and to identify "tipping points" of demand at which triage would result in more survivors.Setting: Not applicable as this was a data-free mathematical modeling exercise.Main Results: We identified circumstances in which triage would be expected to result in more survivors and circumstances in which it would not. In some scenarios, excluding patient groups solely on the basis of anticipated length of stay could be effective due to a more efficient use of critical care bed days.Conclusions: The impact of triage is dependent on the level of demand and on the scale of achievable differences between included and excluded groups in terms of anticipated length of stay and critical care survival. It cannot be assumed that triage can or will result in fewer deaths. It should be remembered that there are considerations other than population-level short-term survival when determining the objectives of triage and its ethical implementation. (Crit Care Med 2011; 39: 179-183)

Recently, a genetic variant of 2009 H1N1 has become the predominant virus circulating in the southern hemisphere, particularly Australia and New Zealand, and in Singapore during the winter of 2010. It was associated with several vaccine breakthroughs and fatal cases. We analyzed three reported mutations D94N, N125D, and V250A in the HA protein of this genetic variant. It appeared that the reason for D94N and V250A to occur in pairs was to maintain the HA binding to human type receptor, so the virus could replicate in humans efficiently. Guided by this interpretation, we discovered a new mutation V30A that could compensate for N125D as V250A did for D94N. We demonstrated that the presence of amino acids 30A and 125N in HA enhanced the binding to human type receptor, while 30V and 125D favored the receptors of avian type and of A/South Carolina/1/18 (H1N1). Furthermore, a combination of 94D, 125D, and 250V made the primary binding preference similar to that of A/South Carolina/1/18 (H1N1) and a combination of 94N, 125D, and 250A resulted in the primary binding affinity for avian type receptor, which clearly differed from that of A/California/07/2009 (H1N1), a strain used in the vaccine for 2009 H1N1. We also re-examined the origin of 2009 H1N1 to refine our knowledge of this important issue. Although the NP, PA, PB1, and PB2 of 2009 H1N1 were closest to North American swine H3N2 in sequence identity, their interaction patterns were closest to swine H1N1 in North America.

This paper describes our experience of the novel H1N1 pandemic at Tygerberg Children’s Hospital. Twenty-six children with polymerase chain reaction (PCR)-confrmed H1N1 infection were hospitalised between 1 July 2009 and 30 September 2009. Seventy-three per cent (19/26) had underlying co-morbidities. Cough and/or dyspnoea (92%) and fever (54%) were the main presenting features. Seven children (27%) required intensive care management, with one death. Nosocomial transmission was suspected in 6/26 (23%) children. The H1N1 pandemic caused morbidity especially among low birthweight, premature infants. There is a need for continued vigilance, improved isolation facilities and appropriate immunisation.

Evaluating the impact of different social networks on the spread of respiratory diseases has been limited by a lack of detailed data on transmission outside the household setting as well as appropriate statistical methods. Here, from data collected during a H1N1 pandemic (pdm) influenza outbreak that started in an elementary school and spread in a semirural community in Pennsylvania, we quantify how transmission of influenza is affected by social networks. We set up a transmission model for which parameters are estimated from the data via Markov chain Monte Carlo sampling. Sitting next to a case or being the playmate of a case did not significantly increase the risk of infection; but the structuring of the school into classes and grades strongly affected spread. There was evidence that boys were more likely to transmit influenza to other boys than to girls (and vice versa), which mimicked the observed assortative mixing among playmates. We also investigated the presence of abnormally high transmission occurring on specific days of the outbreak. Late closure of the school (i.e., when 27% of students already had symptoms) had no significant impact on spread. School-aged individuals (6–18 y) facilitated the introduction and spread of influenza in households, but only about one in five cases aged >18 y was infected by a school-aged household member. This analysis shows the extent to which clearly defined social networks affect influenza transmission, revealing strong between-place interactions with back-and-forth waves of transmission between the school, the community, and the household.

As we enter the year of 2011, the 2009 H1N1 pandemic influenza virus is in the news again. At least 20 people have died of this virus in China since the beginning of 2011 and it is now the predominant flu strain in the country. Although this novel virus was quite stable during its run in the flu season of 2009-2010, a genetic variant of this virus was found in Singapore in early 2010, and then in Australia and New Zealand during their 2010 winter influenza season. Several critical mutations in the HA protein of this variant were uncovered in the strains collected from January 2010 to April 2010. Moreover, a structural homology model of HA from the A/Brisbane/10/2010(H1N1) strain was made based on the structure of A/California/04/2009 (H1N1). The purpose of this study was to investigate mutations in the HA protein of 2009 H1N1 from sequence data collected worldwide from May 2010 to February 2011. A fundamental problem in bioinformatics and biology is to find the similar gene sequences for a given gene sequence of interest. Here we proposed the inverse problem, i.e., finding the exemplars from a group of related gene sequences. With a clustering algorithm affinity propagation, six exemplars of the HA sequences were identified to represent six clusters. One of the clusters contained strain A/Brisbane/12/2010(H1N1) that only differed from A/Brisbane/10/2010 in the HA sequence at position 449. Based on the sequence identity of the six exemplars, nine mutations in HA were located that could be used to distinguish these six clusters. Finally, we discovered the change of correlation patterns for the HA and NA of 2009 H1N1 as a result of the HA receptor binding specificity switch, revealing the balanced interplay between these two surface proteins of the virus.

The Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Japan, has developed a fully automatic system for daily reporting of ILI (influenza-like illness) patients prescribed Oseltamivir and Zanamivir. The system collected data on the number of prescriptions from approximately 3350 pharmacies, which account for almost 7% of all pharmacies in Japan, and published the number online on a daily basis, except for Sundays. On the basis of these data, we further estimated R v and predicted its course every Monday using a very simple SIR model with data from previous studies. This paper summarizes our real-time estimation and prediction of ILI patients in the 2009 influenza A/H1N1 pandemic. The estimate on November 29 resulted in an R v of 1.72 (95%CI [1.69, 1.75]). The model predicted that the peak of the epidemic would be reached on December 23 2009 [December 14, 2009, January 2, 2010] with an estimated number of ILI patients of 227,000 [193,000, 262,000]. The cumulative number of ILI patients over the period would be as high as 17.8% [16.6, 19.0%] of the total population of Japan. This information was circulated weekly among central and local government officers in charge of pandemic control to provide updates on the pandemic situation and to aid their decision-making on control strategies. In conclusion, for the first time in the world, we successfully demonstrated real-time estimation and prediction for the entire course of a pandemic, and which could be used routinely for planning counter-measures.

Severe influenza illnesses, hospitalizations, and deaths among pregnant women were reported during the last U.S. influenza season, when the 2009 H1N1 pandemic strain was again the predominant circulating virus. What lessons can we apply from the 2009 pandemic?

Background: H1N1 pandemic posed a serious threat to world health community. We described the epidemiology of H1N1 in western Rajasthan. Materials and Methods: This study was a retrospective descriptive analysis all 686 confirmed cases of H1N1 in western Rajasthan from the month of August 2009 to March 2010 and conducted in hospitals attached to Dr. S. N. Medical College, Jodhpur. Data were analyzed using GraphPad software (GraphPad Prism ® .) and Chi-square test. Results: A total of 686 cases were confirmed positive with positivity ratio of 32.3%. The overall case fatality rate was 11.7%. The highest number of cases (50.7%) and deaths (60%) were seen during the month of Decemberand among the age group of 16-30 years. About 54% of patients were males. Mortality rate was higher in females (64%). Although, there were more cases reported from the urban area (60%), the mortality was higher in patients of the rural area (62.5%). The mortality rate among pregnant women was also higher than other groups. Conclusions: H1N1 influenza occurred predominantly among the younger age group with high case fatality especially among postpartum women in the study population