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					2009 flu pandemic
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            This article documents a current pandemic. Information may change
            rapidly as the event progresses.

                          Laboratory-confirmed human cases by country

                                                Cases                       Deaths
                                               Laboratory                  Confirmed
                                               confirmed                  (Suspected)‡

              WHO totals[1]†                    44,287                        180

              ECDC totals[2]                    51,702                        230

                  Total                         52,198                        257

Mexico                                          7,624[3]                113[3] (77)[4][5]

United States                                  21,065[6]#                    112[7]

Canada                                          5,710[8]                     13[8]

Argentina                                       1,080[9]                    7[10][11]

Chile                                          4,476[12]                    5[12][13]

Colombia                                        68[2][14]                   2[1][14]

United Kingdom                                 2,506[15]                      1[16]

Australia                                      2,436[17]                      1[2]

Guatemala                                       208[18]                       1[1]

Costa Rica                                      177[19]                       1[1]

Dominican Republic                               94[20]                       1[1]

Japan                                           740[21]                        0

Thailand                                        705[22]                        0

Spain                                            522[2]                        0

Philippines                                     428[23]                        0
China                                                     356[24]                               0

Panama                                                    330[25]                               0

Hong Kong                                                 320[26]                               0

Germany                                                  275[27][2]                             0

Israel                                                    271[28]                               0

New Zealand                                               258[29]                               0

Peru                                                      200[30]                               0

Other                                                     2,349                                 0

       [show]Countries with fewer than 200 confirmed cases and no confirmed deaths
                             [show]Graphs of case progression
On June 16, 2009, New York City health department estimated 500,000 in the city infected.[71]On May 15,
  2009, the CDC's Jan Jernigan estimated that there were "probably upwards of maybe 100,000" cases in
                                          the United States.[72]
     On May 29, 2009, Dr. Gregory Poland, director of Mayo Clinic's Vaccine Research Group, said that
 these numbers are probably a "gross underestimate," because many countries don't test and those that do
                                   miss many people with the virus.[73]
Number of countries with confirmed cases: 99
 Include Puerto Rico. Some U.S. authorities have stopped testing all but seriously ill patients, [70] so many
cases may not be confirmed.

     Includes French Polynesia and Martinique.

The 2009 flu pandemic[74] is a global outbreak of a new strain of influenza A virus
subtype H1N1, identified in April 2009 and commonly referred to as swine flu, which
infects and is transmitted between humans. It is thought to be a mutation—more
specifically, a reassortment—of four known strains of influenza A virus subtype H1N1:
one endemic in humans, one endemic in birds, and two endemic in pigs (swine).[75] A
June 17, 2009 update by the U.N.'s World Health Organization (WHO) states that "76
countries have officially reported 39,620 cases of influenza A(H1N1) infection,
including 167 deaths".[76]

The WHO officially declared the outbreak to be a pandemic on June 11, but stressed
that the new designation was a result of the global spread of the virus, not its severity
which can be mild, moderate, or severe. The WHO stated the pandemic appears to have
moderate severity in comparatively well-off countries, however it is prudent to
anticipate a bleaker picture as the virus spreads to areas with limited resources, poor
health care, and a high prevalence of underlying medical problems.[77] The case fatality
rate (CFR) of the pandemic strain is estimated at 0.4% (range 0.3%-1.8%)[78]

The virus typically spreads from coughs and sneezes or by touching contaminated
surfaces and then touching the nose or mouth.[79] WHO Director-General Margaret
Chan says probably it will be September 2009 before the first doses of a vaccine for the
2009 flu pandemic strain will become available and even then, "there will be limited
supply of vaccine".[80] There is also concern that the virus could mutate later in the year
and become more virulent and less susceptible to any vaccine developed to protect from
an earlier strain. This concern is partly due to the memory of the 1918 flu pandemic,
which killed approximately 600,000 in the United States alone, and was preceded by a
mild "herald" wave of cases in the spring.[81]

Up until May 24, 2009 nearly 90% of reported deaths had taken place in Mexico. This
has led to speculation that Mexico may have been in the midst of an unrecognized
epidemic for months prior to the current outbreak, thereby showing a fatality rate that
was much higher than it would have been if earlier cases had been counted.[82]
According to the US Centers for Disease Control and Prevention, the fact that the flu's
infection activity is now monitored more closely may also help explain why more flu
cases than normal are being recorded in many countries.[81]


        1 Historical context
        2 Initial outbreaks
             o 2.1 Mexico
             o 2.2 United States
        3 Response
             o 3.1 Data reporting and accuracy
             o 3.2 Travel advisories
             o 3.3 Actions concerning pigs
        4 Virus characteristics
             o 4.1 Virus origins
             o 4.2 Rate of infection
             o 4.3 Virulence
             o 4.4 Mutation potential
        5 Pandemic declared
             o 5.1 WHO to focus on developing countries
             o 5.2 Northern Hemisphere
             o 5.3 Southern Hemisphere
        6 Symptoms and expected severity
             o 6.1 Most cases mild
             o 6.2 Symptoms that may require medical attention
             o 6.3 Underlying conditions may worsen symptoms
        7 Prevention
             o 7.1 Containment and quarantine
             o 7.2 School closures
             o 7.3 Spread in the workplace
             o 7.4 Hygiene
                      7.4.1 Airborne transmission
                      7.4.2 Contact with infected surfaces
                      7.4.3 No danger from pork consumption
                     7.4.4 Airline hygiene precautions
      8 Vaccination
      9 Treatment
          o 9.1 Home treatment remedies
          o 9.2 Antiviral drugs
      10 Emergency planning
      11 See also
      12 References
          o 12.1 Sources and notes
          o 12.2 Further reading

[edit] Historical context
Annual influenza epidemics are estimated to affect 5–15% of the global population,
resulting in severe illness in 3–5 million patients and causing 250,000–500,000 deaths
worldwide. In industrialized countries severe illness and deaths occur mainly in the
high-risk populations of infants, the elderly, and chronically ill patients.[83]

In addition to these annual epidemics, Influenza A virus strains caused three major
global epidemics during the 20th century: the Spanish flu in 1918, Asian flu in 1957 and
Hong Kong flu in 1968–69. These pandemics were caused by strains of Influenza A
virus that had undergone major genetic changes and for which the population did not
possess significant immunity.[83][84] The overall effects of these pandemics and
epidemics are summarized in the table below.

                             20th century flu pandemics

                        Influenza A                                              Case
                                        People infected        Deaths
 Pandemic     Year          virus                                               fatality
                                           (approx)             (est.)
                          subtype                                                 rate

  1918 flu    1918–                     500 million - 1      20 to 100
                        H1N1[85][86]                                            >2.5%[90]
 pandemic       19                          billion       million[87][88][89]

              1956-                                                             <0.1% ?
 Asian flu                H2N2[85]                          2 million[89]          [90]

Hong Kong 1968–
                          H3N2[85]                          1 million[89]       <0.1%[90]
   flu      69
                                           5-15% (340
               Every mainly A/H3N2,                            250,000-
Seasonal flu                                million - 1                         <0.05%
                year A/H1N1, and B                            500,000[83]

          Not a pandemic, but listed to compare the several flu strains endemic in
       humans which produce seasonal flu with the rare new strain that results in a flu

The influenza virus has also caused several pandemic threats over the past century,
including the pseudo-pandemic of 1947, the 1976 swine flu outbreak and the 1977
Russian flu, all caused by the H1N1 subtype.[84] The world has been at an increased
level of alert since the SARS epidemic in Southeast Asia (caused by the SARS
coronavirus).[92] The level of preparedness was further increased and sustained with the
advent of the H5N1 bird flu outbreaks because of H5N1's high fatality rate, although the
strains currently prevalent have limited human-to-human transmission (anthroponotic)
capability, or epidemicity.[85][93]

People who contracted flu prior to 1957 may have some immunity. A May 20, 2009
New York Times article stated: ―Tests on blood serum from older people showed that
they had antibodies that attacked the new virus, Dr. Daniel Jernigan, chief flu
epidemiologist at the Centers for Disease Control and Prevention, said in a telephone
news conference. That does not mean that everyone over 52 is immune, since some
Americans and Mexicans older than that have died of the new flu.‖[94]

[edit] Initial outbreaks
Further information: 2009 flu pandemic timeline
Further information: 2009 flu pandemic table

It is not known where the virus originated.[95][96] Analysis has suggested that the H1N1
strain responsible for the current outbreak first evolved around September 2008 and
circulated in the human population for several months before the first cases were
identified as being due to a new strain.[95][97][98]

[edit] Mexico

Further information: 2009 flu pandemic in Mexico

The virus was first reported in two U.S.children in March, but health officials have said
that it apparently infected people as early as last January in Mexico.[99] The outbreak
was first detected in Mexico City on March 18, 2009 where surveillance began picking
up a surge in cases of influenza-like illness. "In early April, Mexico had noticed that it
had high numbers of serious respiratory illnesses and some deaths. It began sending
samples to Canada and the United States, asking for help genotyping the new virus."[100]
Health Secretary Jose Angel Cordova confirmed that a 4-year-old boy was part of an
outbreak in Veracruz state that began in February. Residents of the town of Perote
worried at the time that they had contracted a new and aggressive flu, and publicly
demonstrated against the pig farm they initially blamed for their illness. It was only
after U.S. labs confirmed a swine flu outbreak that Mexican officials sent the boy's
sample in for testing, and it tested positive for swine flu.[101] While there was
speculation that the outbreak may have started at the pig plant in Veracruz,[102] the plant
owners said that no pigs had tested positive for the virus.[103]

After the outbreak was officially announced, Mexico immediately requested material
support from the U.S. and worked closely with the CDC and Canada, sending them
suspected samples for testing. Soon after, the CDC helped Mexico build their own lab
capability to do faster diagnosis and confirmation of the H1N1 virus in Mexico.
According to one commentator, "in the face of mounting hysteria, the response of both
Mexico and the United States was an almost perfect display of the cooperation and
partnership . . . ."[104] Within a few days Mexico City was "effectively shut down," and
some countries hastily canceled flights to Mexico while others halted trade. Although
many in the U.S. called for shutting the border to help contain the spread, President
Obama rejected the idea and Homeland Security Secretary Janet Napolitano called it
"pointless," as the virus had already crossed into the U.S., and felt that "closing the
border would have done nothing more than wreak economic havoc on both

As the outbreak spread throughout Mexico and into the U.S., however, scientists were
trying to understand why there were so many deaths in Mexico while infections in the
United States and Canada were relatively mild and not unusually dangerous compared
to seasonal flus. "If that continues to be true," wrote the Washington Post, "then it may
help explain the mysteriously high mortality in Mexico." The newspaper noted that "it
may be that Mexico already has had hundreds of thousands, and possibly millions, of
cases—all but the most serious hidden in the 'noise' of background illness in a crowded
population."[82] They added, "the fact that most people infected in other countries had
recently been to Mexico—or were in direct contact with someone who had been—is
indirect evidence that the country may have been experiencing a silent epidemic for
months."[82][105] A study published May 11, 2009 in the journal Science estimated
Mexico alone may have already had 23,000 cases of swine flu by April 23, 2009, the
day it announced the epidemic.[106]

As experts struggled to explain why so many deaths had initially occurred in Mexico
and nowhere else, the CDC on May 1, 2009 suggested a simple explanation: "there are
many cases in Mexico, most are mild, and just the bad ones have been seen so far."[107]
It noted that recent severe cases had focused on patients seeking care in hospitals and
acknowledged that there could in fact be a large number of undetected cases of illness,
which would explain the much higher mortality rate. Other experts agreed: "The central
question every flu expert in the world would like answered, is how many mild cases
Mexico has had," said Dr. Martin Cetron, director of global migration and quarantine
for the Centers for Disease Control, in an interview. "We may just be looking at the tip
of the iceberg, which would give you a skewed initial estimate of the case fatality rate,"
as he also speculated that there may have been tens of thousands of unreported mild
infections, which would then make the number of deaths seemingly low, and as the flu
spreads, the number of people who become seriously ill would remain relatively

[edit] United States
Further information: 2009 flu pandemic in the United States

The new strain was first diagnosed in two children by the CDC, first on April 14, 2009
in San Diego County, California and a few days later in nearby Imperial County,
California[108] (it was not identified as a new strain in Mexico until 24 April[109]).
Neither child had been in contact with pigs.[108][110]

[edit] Response
See also: 2009 swine flu outbreak by country

   Deaths   Confirmed cases    Unconfirmed or suspected cases See also: H1N1 live map,
WHO updates

According to Dr. Thomas Frieden, the new CDC director on June 8, 2009: "There‘s no
question that a new strain of influenza spreading rapidly throughout the world is a major
problem and requires a major response. So far, it doesn‘t seem to be any more severe
than seasonal flu, but seasonal flu kills 36,000 Americans a year."[111]

Federal officials and other groups felt that six years of worrying about H5N1 avian flu
did much to prepare for the current swine flu outbreak. Jeffrey Levi, executive director
of the monitoring group Trust for America‘s Health, notes that after H5N1 emerged
widely in Asia in 2003, killing about 60 percent of the humans infected by it, many
countries took steps to prevent any crisis that would emerge if that virus were to acquire
the ability to jump easily from human to human, and the measures taken in preparation
were helpful. Levi also said that little vaccine would be available by this autumn, if
there were no major delays in production.[112]

Dr. Schuchat, summarizing much of the country's quick response says "This really was
a wake-up call for the world. We actually have been preparing for a pandemic for many
years now." The avian flu outbreak more than five years ago led the CDC and state and
local public health departments to prepare for a nationwide pandemic. "I would say
these exercises worked immensely," Schuchat said, especially development of disease
diagnosis and tracking and communication. "There has been a lot of payoff for worrying
about bird flu."[113]

But recognizing that the responses were not perfect, she also said the CDC will now use
the current lull to take stock of the United States's response to the new H1N1 flu and
attempt to patch any gaps in the public health safety net before flu season starts this
autumn. She cited a new report which found that recent cuts in public health
departments have meant many did not have adequate resources to carry out flu plans.
The U.S. Government Accountability Office also said the U.S. flu preparedness plan
needed improvement, including better coordination between federal, state and local
governments and the private sector.[114]

Michael Gardam, director of infectious disease prevention and control at the Ontario
Agency for Health Protection and Promotion, said in an interview with the CBC that an
outbreak of swine flu in Ontario, Canada's most populous province, would not be as
serious as the 2003 SARS epidemic.[115]

[edit] Data reporting and accuracy

See also: National Influenza Centers, Disease surveillance, and Clinical surveillance

Influenza surveillance information "answers the questions of where, when, and what
influenza viruses are circulating. It can be used to determine if influenza activity is
increasing or decreasing, but cannot be used to ascertain how many people have become
ill with influenza".[116]

The initial outbreak received a week of near-constant media attention.[117]
Epidemiologists cautioned that the number of cases reported in the early days of an
outbreak can be very inaccurate and deceptive due to several causes, among them
selection bias, media bias, and incorrect reporting by governments.[118] Inaccuracies
could also be caused by authorities in different countries looking at differing population
groups.[118] Furthermore, countries with poor health care systems and older laboratory
facilities may take longer to identify or report cases.[119]

In late April, experts predicted there would be 2,000 to 2,500 U.S. cases by the end of
May. However, by May 15, 2009, the Centers for Disease Control and Prevention
estimated that there were "upwards of 100,000" cases in the country, even though only
7,415 had been confirmed at that point. The CDC in late May stated that counting
confirmed cases had become "largely irrelevant," and switched instead to its traditional
surveillance systems for monitoring flu-like symptoms by looking for patterns, clusters
and changes in flu activity nationwide. According to the CDC, surveillance methods,
along with rapid isolation and treatment, only makes sense at the very earliest stage of
an outbreak, and "becomes irrelevant" once the virus is spreading widely within the
community, as it is in the United States.[120]

In some instances, governments accused other countries of intentionally underreporting
cases. Moscow, for instance, hinted that the Caribbean nation of the Dominican
Republic was underreporting its number of swine flu cases to "boost tourism," and on
May 30 advised its citizens not to travel there.[121] In early May, Cuba's Fidel Castro
accused Mexico of hiding the scope of the epidemic until after President Obama visited
the country in April, and a study published in the journal Science on May 11, estimated
Mexico alone may have had 23,000 cases of swine flu by April 23, the day it announced
the epidemic.[122]

In the U.S. data accuracy has also become an issue, with some school districts deciding
to keep the names of students and schools that have reported infections confidential, one
stating that "it would not be fair to single out one school," since doing so would likely
trigger requests by parents to have their children tested despite their health not being in
danger, and the schools lack the ability to test everyone.[123] Dr. Hector Gonzalez,
Director of the Laredo Health Department, said that according to CDC guidelines,
physicians only need to submit samples for testing if the patient is a child under 5 years
of age, is pregnant, has an underlying medical condition or is suffering from respiratory
distress requiring urgent care.[124]

In early June, WHO and the U.S. FDA acknowledged that a new laboratory test used to
identify the potentially deadly virus is only about 90 per cent accurate, and suggested
that the newly developed rRT-PCR "rapid" testing method gives only a "presumptive
positive" rather than a "definitive positive" result for H1N1 influenza. As this test is
currently used in Australia, reports indicate that Australians may have been falsely
diagnosed with human swine flu while others with the disease may have been sent home
with a negative result.[125]

[edit] Travel advisories

The new strain has spread widely beyond North America with confirmed cases in
eighty-nine countries. Initially, most cases outside North America were following recent
travel to Mexico or the U.S. However by May 15 in-country transmission had been
reported from Canada, Japan, Panama, the UK, Spain, Germany, Australia, Italy, and
Belgium[126], and as of June 17 most countries within the European Union had
documented in-country transmission[127] as had many countries worldwide.[77]

Many countries had earlier advised citizens to avoid travelling to infected areas and
were monitoring visitors returning from flu-affected areas for flu symptoms. WHO
guidance from 7 May recommends no travel restrictions based on this strain of
influenza stating that "Scientific research based on mathematical modelling shows that
restricting travel would be of limited or no benefit in stopping the spread of disease".[128]
The CDC downgraded a previous "Travel Health Warning" for Mexico to a "Travel
Health Precaution" on May 15 referring to the reduction in infections in Mexico and the
reduced overall risk of the virus.[129]

[edit] Actions concerning pigs

Main article: 2009 swine flu outbreak actions concerning pigs
Swine infections

According to researchers cited by The New York Times, "based on its genetic structure,
the new virus is without question a type of swine influenza, derived originally from a
strain that lived in pigs".[130] This origin gave rise to the nomenclature "swine flu",
largely used by mass media in the first days of the epidemic. Despite this origin, the
current strain is a human-to-human transmitted virus, requiring no contact with swine.
On May 2 it was announced that a carpenter on an Alberta farm who had returned from
Mexico had transmitted the disease to a herd of pigs, showing that the disease can still
move between species.[131]

Pork import bans

International health officials from the CDC, WHO, FAO, OIE and other food
organizations have reaffirmed that pork is safe to eat and hogs are not to blame for the
epidemic. However, as of early June, China, Russia and more than a dozen other
countries were still banning pork imports from the U.S.

On June 12, the World Trade Organisation (WTO) planned to highlight the pork bans in
a forthcoming report on protectionism due in the coming weeks. WHO's World
Organisation for Animal Health (OIE) and U.N.'s Food and Agriculture Organisation
reiterated that pork is not a source of infection and is safe to eat provided it is prepared
properly. However, the WTO report is likely to limit itself to listing the meat import
restrictions and "not comment on whether they are justified, for fear of prejudging any
trade disputes that arise from them." Russia is not a WTO member, and along with
Argentina, are among the most prominent countries still banning pork imports from
affected countries.[132]

This has also led some U.S. industry and government officials to "speculate that the
issue is more about market share than health concerns." The bans, instituted in the wake
of the swine flu outbreak, cost the U.S. hog industry millions of dollars every week. "It's
politics and not science," said John Lawrence, a professor and livestock economist at
Iowa State University. "The product is safe. So why restrict imports?" About 20 percent
of U.S. pork is exported, and China and Russia are among the biggest

Pig culls

In late April, 2009 the Egyptian Government began to kill all 300,000 pigs in Egypt,
despite a lack of evidence that the pigs had, or were even suspected of having, the
virus.[137] This led to clashes between pig owners and the police in Cairo. Most of
Egypt's 80-million population are Muslims, whose religion forbids them from eating
pork, but an estimated six to ten percent are Christian Copts, who eat pork.[138][139][140]
On June 5, the UK-based Compassion in World Farming organization warned Egypt
that its brutal measures and its mass slaughter of pigs could negatively affect Egypt's
tourism industry. Philip Lymbery the chief executive of the group was quoted saying
that "Britons and people from around the world have joined the international storm of
protest against this atrocity in Egypt, with many saying they'll no longer consider Egypt
as a possible holiday destination."[141]

In Canada in early June, an Alberta pig farmer whose herd was infected with the new
swine flu virus culled his entire herd. In May he had already culled 500 animals from
his herd which was believed to have been infected by a worker who had been
vacationing in Mexico. The farm owner said the animals cannot be marketed because
they are under quarantine and he is facing a problem with overcrowding.[142]

Surveillance of pig populations

At the beginning of June 2009, the U.S. Agriculture Department said it would launch a
pilot surveillance project to look for new strains of flu virus in pigs. Some experts claim
that global health officials have underestimated the risk that pig herds might be a source
of new influenza strains, choosing instead to focus on the threat of bird flu. "This virus
most likely evolved from recent swine viruses," Gerardo Nava of the National
Autonomous University of Mexico wrote in a report published in the online journal
Until recently, health experts have done very little surveillance of influenza among
pigs—even though the virus is very common in the animals and just as transmissible as
it is among people. Flu viruses have also been shown to pass from pigs to people and
from people to pigs. "These observations also reiterate the potential risk of pig
populations as the source of the next influenza virus pandemic," Nava and colleagues
wrote. "Although the role of swine as 'mixing vessels' for influenza A(H1N1) viruses
was established more than a decade ago, it appears that the policy makers and scientific
community have underestimated it. . . . The problem is that the virus is recombining (in
the pig's body) and getting new sequences, new genes."[143]

Nomenclature debate

H1N1 influenza virus

Some authorities object to calling the flu outbreak "swine flu". U.S. Agriculture
Secretary Tom Vilsack expressed concerns that this would lead to the misconception
that pork is unsafe for consumption.[144] The CDC began referring to it as "Novel
influenza A (H1N1)".[145] In the Netherlands, it was originally called "pig flu", then
called "Mexican flu" by the national health institute and in the media. South Korea and
Israel briefly considered calling it the "Mexican virus".[146] Later, the South Korean
press used "SI", short for "swine influenza". Taiwan suggested the names "H1N1 flu" or
"new flu", which most local media now use.[147] The World Organization for Animal
Health proposed the name "North American influenza".[148] The European Commission
adopted the term "novel flu virus".[149]

After initially opposing changing the name from "swine flu",[150] the WHO announced
they would refer to the new influenza virus as Influenza A (H1N1) or "Influenza A
(H1N1) virus, human",[149] also to avoid suggestions that eating pork products carried a
risk of infection.[151][152]

The outbreak was also called the "H1N1 influenza",[153] "2009 H1N1 flu",[154][155] or
"swine-origin influenza".[156] However, Seth Borenstein, writing for the Associated
Press quoted several experts who objected to any name change at all.[157]

[edit] Virus characteristics
Main article: 2009 flu pandemic virus
The virus is a novel strain of influenza. Existing vaccines against seasonal flu provide
no protection, and there is no vaccine for this strain. A study at the US Centers for
Disease Control and Prevention published in May 2009 found that children had no
preexisting immunity to the new strain but that adults, particularly those over 60, had
some degree of immunity. Children showed no cross-reactive antibody reaction to the
new strain, adults aged 18 to 64 had 6-9%, and older adults 33%.[158][159] It was also
determined that the strain contained genes from four different flu viruses: North
American swine influenza, North American avian influenza, human influenza, and two
swine influenza viruses typically found in Asia and Europe. Further analysis showed
that several of the proteins of the virus are most similar to strains that cause mild
symptoms in humans, leading virologist Wendy Barclay to suggest on May 1 that the
initial indications are that the virus was unlikely to cause severe symptoms for most
people.[160] Scientists in Winnipeg completed the first full genetic sequencing of the
virus on 6 May.[161]

[edit] Virus origins

In early June 2009, using computational methods developed over the last ten years at
Oxford, Dr Oliver Pybus of Oxford University's Department of Zoology and his team
attempted to reconstruct the origins and timescale of the 2009 flu pandemic. He claims
"Our results show that this strain has been circulating among pigs, possibly among
multiple continents, for many years prior to its transmission to humans." The research
team that worked on this report also believe that it was "derived from several viruses
circulating in swine," and that the initial transmission to humans occurred several
months before recognition of the outbreak. The team concluded that "despite
widespread influenza surveillance in humans, the lack of systematic swine surveillance
allowed for the undetected persistence and evolution of this potentially pandemic strain
for many years."[162]

Structure of the influenza virion. The hemagglutinin (HA) and neuraminidase (NA)
proteins are shown on the surface of the particle. The viral RNAs that make up the
genome are shown as red coils inside the particle and bound to ribonucleoproteins

According to the researchers, movement of live pigs between Eurasia and North
America "seems to have facilitated the mixing of diverse swine influenza viruses,
leading to the multiple reassortment events associated with the genesis of the (new
H1N1) strain." They also stated that this new pandemic "provides further evidence of
the role of domestic pigs in the ecosystem of influenza A."[99]

[edit] Rate of infection
According to the World Health Organization, 88 countries had officially reported
44,287 cases of infection, including 180 deaths, as of June 19, 2009.[163] Notably, the
cases in Argentina, Australia and El Salvador more than doubled in each of WHO
reporting cycle updates 41 and 42 (29 May and 1 June respectively). But according to
CDC experts, however, the flu outbreak in the U.S. is dying down in the country as a
whole.[164] As of May 30, Wisconsin had more cases than any other state: 1,430, but
Wisconsin officials said that this was "nothing to worry about," pointing out that the
higher numbers largely reflected the state's efficiency in testing suspected cases.
Spokesman Seth Boffeli added that the Wisconsin cases had been relatively mild.[165]

Some news reports indicated that the swine flu was spreading more widely than official
figures indicate, with outbreaks in Europe and Asia following those of North and South
America. According to the CDC, about one in 20 cases was being officially reported in
the U.S.[166] In the U.K., according to virologist professor John Oxford, the virus may be
300 times more widespread than health authorities have said, with total infections
estimated at 30,000 as of 24 May 2009.[167] Oxford's estimate comes as leading
scientists are warning that estimates by the U.K. and other governments on the spread of
the disease are "meaningless" and hiding its true extent. He also estimates that Japan
may have approximately 30,000 cases. Professor Michael Osterholm, one of the world's
top flu experts and an adviser to the U.S. government, also called the official figures
"meaningless," claiming that officials were not hiding cases, but were not hunting very
hard to find them.[167] Oxford also believes that thousands of people have caught the
virus and "suffered only the most minor symptoms," or none at all, over the past weeks.

Although the United States was past its flu season, the Southern Hemisphere, where the
virus had also spread, was entering the cold months when influenza cases increase.
Jeffery Taubenberger, a National Institutes of Health researcher, stated that "I am loath
to make predictions about what an influenza virus that mutates so rapidly will do," but
he believes it will spread across the planet. Other experts concur, adding that "the new
swine flu virus is almost certain to eventually infect every continent and country,
although that may take years."[82]

[edit] Virulence

Most fatalities have been in Mexico (72%, as of June 5, 2009) where, according to the
New York Times, the deaths from the illness have primarily been young, healthy
adults.[168] The WHO Rapid Pandemic Assessment Collaboration estimated the case
fatality ratio in Mexico prior to mid-April to be 0.4%. This is comparable to that of the
1957 Asian flu,[169][170] a category 2 pandemic that killed approximately 1 to 4 million

By May 27, 2009, the CDC was reporting 6,764 U.S. cases in 47 states resulting in
fourteen deaths, but noted that for the most part, the infections continue to be mild—
similar to seasonal flu—and recovery is extremely quick.[172] Furthermore, analysis
hasn't turned up any of the markers which scientists associate with the virulence of the
1918 "Spanish flu" virus, said Nancy Cox, head of the CDC's flu lab. In the state of
New York, as of June 7, eight people have died from the outbreak, which has sparked
"panic in schools, fear in hospitals and unease on the subways'," writes the New York
Daily News. Belinda Ostrowsky, a doctor at Montefiore Medical Center's division of
infectious diseases notes that the deaths so far are "a tiny fraction of the up to 2,000
New Yorkers who die every year from seasonal flu - with barely a public murmur." She
adds, "When there's something that's new and unknown, it scares people."[173]

As of June 19, 2009, most deaths have now occured in the United States. With 115

[edit] Mutation potential

On May 22, 2009, WHO chief Dr. Margaret Chan said that the virus must be closely
monitored in the southern hemisphere, as it could mix with ordinary seasonal influenza
and change in unpredictable ways. "In cases where the H1N1 virus is widespread and
circulating within the general community, countries must expect to see more cases of
severe and fatal infections," she said. "This is a subtle, sneaky virus."[174]

This led other experts to become concerned that the new virus strain could mutate over
the coming months. Guan Yi, a leading virologist from the University of Hong Kong,
for instance, described the new H1N1 influenza virus as "very unstable", meaning it
could mix and swap genetic material when exposed to other viruses. During an
interview he said "Both H1N1 and H5N1 are unstable so the chances of them
exchanging genetic material are higher, whereas a stable (seasonal flu) virus is less
likely to take on genetic material." The H5N1 virus is mostly limited to birds, but in rare
cases when it infects humans it has a mortality rate of between 60% to 70%.[175] Experts
worry about the emergence of a hybrid of the more virulent Asian-lineage HPAI (highly
pathogenic avian influenza) A/H5N1 strain (media labeled "bird flu") with more
human-transmissible Influenza A strains such as this novel 2009 swine-origin A/H1N1
strain (media labeled "swine flu"), especially since the H5N1 strain is and has been for
years endemic in birds in countries like China, Indonesia, Vietnam and Egypt.[175][176]
(See the suite of H5N1 articles for details.)

Nor had federal health officials in the U.S. dismissed the possibility that the worst was
yet to come. "Far from it," Ann Schuchat of the CDC says, noting that the horrific 1918
flu epidemic, which killed hundreds of thousands in the United States alone, was
preceded by a mild "herald" wave of cases in the spring, followed by devastating waves
of illness in the autumn. "That 1918 experience is in our minds," she said.[164]

However, as of early June 2009, Schuchat reported "encouraging news" regarding any
mutations to date, by announcing that samples of the virus from points around the globe
are "genetically identical" to the strain found in the United States. "We have tested
isolates from a wide geographic area, from the Americas, Europe, from Asia and New
Zealand and we are not seeing variations in isolates from the genetic testing we do
here." Although cases have been relatively mild and patients recover quickly, health
officials have warned that the virus could mutate into a more virulent form, putting
greater numbers of people at risk.[177]

[edit] Pandemic declared

                       [show]WHO pandemic influenza phases (2009)[178]

Further information: CDC Pandemic Severity Index and WHO pandemic phases
On June 11, 2009, the WHO's Chan declared the outbreak had become a pandemic.[179]
The WHO declared a Pandemic Alert Level of six, out of a maximum six, describing
the degree to which the virus had been able to spread among humans. In the same
briefing, Chan stressed that the WHO pandemic level was not linked to severity. On a
separate scale for severity, WHO assessed the global severity as "moderate."[179]

WHO had hesitated to raise its alert level and declare a phase 6 pandemic as the virus to
date has caused generally mild symptoms. Having raised it to level 6 may cause many
countries to adopt a variety of plans, such as shutting borders, banning events and
curtailing travel. A move to phase 6 means that "emergency plans are instantly triggered
around the globe." In addition, at phase 6, many pharmaceutical companies may switch
from making seasonal flu shots to pandemic-specific vaccine, "potentially creating
shortages of an immunization to counter the normal winter flu season."[166] Keiji
Fukuda, WHO's assistant director general of health security and environment, stated that
a move to phase 6 would "signify a really substantial increase in risk of harm to
people." He also cautioned that "one of the critical issues is that we do not want people
to over-panic if they hear that we are in a pandemic situation."

[edit] WHO to focus on developing countries

On June 12, the day after the pandemic was declared, WHO stated that its "primary
concern is to strengthen and support health systems in countries with less resources." It
emphasized that developing countries, where medical care systems are weak and
supplies of antivirals insufficient, "will be the frontline of their battle against pandemic
flu." They also noted that the virus has so far caused mostly mild symptoms in rich
countries such as Canada and the United States, with "most patients recovering without
even going to a doctor." But WHO experts felt that it could prove far more deadly to
poor populations "already weakened by malnutrition, chronic conditions like asthma
and diabetes, or low immunity due to HIV/AIDS." They were also working to make
stocks of antivirals and antibiotics and an eventual pandemic vaccine more accessible
and affordable to developing countries.[180]

[edit] Northern Hemisphere

As of early June 2009, the flu has been reported in 90 countries, mostly in the Northern
Hemisphere, with the United States reporting the most cases — more than 18,000,
including at least 90 deaths, according to the World Health Organization.[181]

As of May 30, 2009, seasonal flu is down, circulating at low levels; while the non-
seasonal new H1N1 flu strain continues to spread and constitutes approximately 82% of
all influenza viruses reported to CDC in the last week of May 2009.[182]

[edit] Southern Hemisphere

It is predicted that the virus will likely continue to spread worldwide, especially in the
Southern Hemisphere, where countries are entering the winter months and the
traditional flu season.[181] South America already has had more than 6,000 cases,
including 4,315 cases and four deaths in Chile and more than 1,000 cases and seven
deaths in Argentina. Keiji Fukuda of WHO has stated that swine flu has already caused
more infections than seasonal influenza at the start of Chile's winter flu season.[183][184]
On June 6, 2009, Australia's second largest city, Melbourne, was reported to be the
"swine flu capital of the world";[185] on 15 June there were 1,210 cases in Victoria,
mostly in Melbourne. In the entire country, confirmed cases have reached 2,436,
including one death.[17] However, according to professor Robert Booy from the
University of Sydney, the reason Victoria has the highest per capita rate of swine flu in
the world "may simply be down to Australia's tough testing regime," and "is probably
the best in the world at detecting this influenza virus." As a result, he feels that the U.S.
and Mexico probably had more cases than have been reported, stating "I would be quite
certain that there's ten to a hundredfold more cases in the US than are confirmed.[186] In
early June WHO and the U.S. Food and Drug Administration suggested that one of the
testing methods used in Australia gives only a "presumptive positive" rather than a
"definitive positive" result for H1N1 influenza and is only about 90 percent accurate. As
a result, they stated that some Australians may have been given a false diagnosis. [125]

[edit] Symptoms and expected severity

CDC's CAPT Dr. Joe Bresee describes symptoms.

The signs of infection with swine flu are similar to other forms of influenza, and include
a fever, coughing, headaches, pain in the muscles or joints, sore throat, chills, fatigue
and runny nose. Diarrhea and vomiting have also been reported in some cases.[187][188] A
study concluded on May 5th, published in the New England Journal of Medicine, found
that 94% of confirmed patients had fever and 92% had cough.[189] People at higher risk
of serious complications included people age 65 years and older, children younger than
5 years old, pregnant women, and people of any age with underlying medical
conditions, such as asthma, diabetes, obesity, heart disease, or a weakened immune
system (e.g., taking immunosuppressive medications or infected with HIV).[187][190]
According to the CDC, more than 70% of hospitalizations in the U.S. have been people
with such underlying conditions.[191]

[edit] Most cases mild

Evidence mounted through May 2009 that the symptoms were milder than health
officials initially feared. As of May 27, 2009, most of the 342 confirmed cases in New
York City had been mild and there had been only 23 confirmed deaths from the
virus.[192] Similarly, Japan had reported 279, mostly mild flu cases, and no deaths,[193]
with the government reopening schools as of May 23, stating that the "virus should be
considered more like a seasonal flu."[194] Furthermore, Australia has had 2,383 cases
with only one death.[17] In Mexico, where the outbreak began in April, Mexico City
officials lowered their swine flu alert level as no new cases had been reported for a

[edit] Symptoms that may require medical attention

Certain symptoms may require emergency medical attention. In children, for instance,
those might include blue lips and skin, dehydration, rapid breathing, excessive sleeping
and significant irritability that includes a lack of desire to be held. In adults, shortness of
breath, pain in the chest or abdomen, sudden dizziness or confusion may indicate the
need for emergency care. In both children and adults, persistent vomiting or the return
of flu-like symptoms that include a fever and cough may require medical attention.[187]

[edit] Underlying conditions may worsen symptoms

WHO reported that almost one-half of the patients hospitalized in the United States had
underlying conditions.[196] "Among 30 patients hospitalized in California," stated the
WHO report, "64 percent had underlying conditions and two of five pregnant women
developed complications, including spontaneous abortion and premature rupture of
membranes." And on June 5, health officials in six states that reported deaths from
swine flu said that all six patients had been diagnosed with other health problems.[197]

However, doctors in New York suggested that people with "underlying conditions" who
had flu symptoms should consult their doctors first. "Visiting an emergency room full of
sick people may actually put them in more danger," wrote the New York Times. Dr.
Steven J. Davidson, the chairman of emergency medicine department at Maimonides
Medical Center in Brooklyn commented "Like the asthmatics, we‘d really prefer that
pregnant women would stay away from the emergency departments." Approximately
one-third of New Yorkers have one of the underlying conditions recognized by the

[edit] Prevention
Further information: Influenza prevention and standard personal precautions against

[edit] Containment and quarantine
Chinese inspectors on an airplane, checking passengers for fevers, a common symptom
of swine flu

On April 28, 2009, WHO's Dr. Keiji Fukuda said that it was too late to contain the
swine flu. "Containment is not a feasible operation. Countries should now focus on
mitigating the effect of the virus," he said.[198] He therefore did not recommend closing
borders or restricting travel, stating that "with the virus being widespread... closing
borders or restricting travel really has very little effects in stopping the movement of
this virus."[198] However, on April 28, the U.S. CDC began "recommending that people
avoid non-essential travel to Mexico."[199] Many other countries confirmed that inbound
international passengers would be screened. Typical airport health screening involves
asking passengers which countries they have visited and checking whether they feel or
appear particularly unwell. Thermographic equipment was put into use at a number of
airports to screen passengers.[200] A number of countries also advised against travel to
known affected regions, while experts suggested that if those infected stay at home or
seek medical care, public meeting places are closed, and anti-flu medications are made
widely available, then in simulations the sickness is reduced by nearly two-thirds.[201]

Some countries began quarantining foreign visitors suspected of having or being in
contact with others who may have been infected. In late May 2009, the Chinese
government confined 21 U.S. students and three teachers to their hotel rooms because a
passenger on their plane to China, suspected of having swine flu, had been seated within
four rows of the students.[202] In Hong Kong, an entire hotel was quarantined with 240
guests after one person staying there was found to have swine flu.[203]

Other governments took or threatened similar actions: The government of Australia
ordered a cruise ship with 2000 passengers to stay at sea because of a swine flu
threat;[204] Egyptians who went on the annual Muslim pilgrimage to Mecca risked being
quarantined upon their return.[205]

At the end of April 2009, when the outbreak began, Russia and Taiwan said they would
quarantine visitors showing symptoms of the virus,[206] and in Southern California, a
marine confirmed to have swine flu was placed in quarantine along with about 30 other
Marines.[207] In early May, Japan quarantined 47 airline passengers in a hotel for a week
after three travelers who arrived on the same plane from Canada tested positive for
H1N1 swine flu,[208] and Mongolia quarantined 109 Russian airline passengers in

On June 8, 2009 China reported that New Orleans Mayor Ray Nagin, his wife and a
security guard, although symptom free, were being held in quarantine after flying on a
plane carrying a passenger who exhibited symptoms. Nagin was traveling to China and
Australia on an economic development trip. However, according to Fox News, "they
don't even allow phone calls," reporting that the Chinese were also screening his calls
"to keep him safe," and have refused even to pass on telephone messages without the
permission of government health officials.[210]

In India, after four airline passengers from London tested positive, the government
ordered that all the 231 passengers of the flight should be administered the anti viral
drug oseltamivir. Health authorities also asked that all the passengers not move out of
their homes till further orders and quarantined at least one of the infected
passengers.[211] And in Egypt, a foreign students' dormitory for the American University
in Cairo, with 140 students, was put under quarantine after two U.S. students were
diagnosed with swine flu.[212][213] According to the BBC, police wearing face masks
"stood at barriers outside the elegant seven-floor AUC dormitory in Zamalek," and
pizzas were delivered to the building during the day but none of the residents were
allowed in or out.[214]

Other governments have given health officials the "increased power" to order people
into quarantine to control the spread of swine flu. The government of New Zealand, for
instance, gave medical officers the power to order people to be quarantined at home if
they have been in close contact with someone who has swine flu.[215]

Some governments have also suggested pre-screening "outbound" passengers from
countries that are thought to have a high rate of infection. India's Minister of State for
Health, for example, said on June 16, that there should be "some kind of screening" for
outbound travellers in the U.S., claiming that most people coming from that country
have been tested positive for influenza A(H1N1) virus. So far, 30 people have tested
positive for swine flu in India. Of them, most had come from the U.S. "The U.S. is the
main source (of swine flu) as far as India is concerned," the health minister stated,
adding that "the government is ready to handle the situation and there is no need to
panic." [216]

[edit] School closures


The early days of the swine flu outbreak led to numerous school closures in a number of
states. However, with signs that the virus was milder than initially feared, schools
reopened and the closures stopped, although officials accept that the virus is continuing
to spread nationwide.

In California, school administrators have noted that throughout the U.S. during the early
weeks in the swine flu outbreak, counties recommended that schools close if a student
was infected, but since early May, as the virus spread widely across the state and
country, public health experts agreed that closing schools wasn't helping contain the
disease. It's not yet known whether school closures will remain relatively rare or
whether more will close before summer break begins, as many schools point out that
closures could become more problematic, with finals and graduations coming up. [217]

In New York City, more than 50 public schools were closed for short periods since
early May, and as of June 5, 2009, with 780 confirmed cases in the state, the majority of
cases have been mild. However, attendance dropped at other schools as worried parents
kept their children home. As of early June, a few schools were still closed. [218]
Similarly, 858 Texas schools had also closed during the outbreak with most now
reopened. And in Connecticut school officials are debating the value of keeping schools
closed, with 480 confirmed cases and most of them mild. There, if more than 15 percent
of the pupils had flu-like symptoms, the school would be advised to close.[219]

Other countries
In Australia, a small number of schools have been closed with some to provide
schoolwork via the websites, email and mail, however some school administrators have
noted major inconveniences. One principal stated "We needed this like a hole in the
head for our year 11 and 12 students - their exams start on June 15, 2009 and that's just
six days away." [220] Schools in New South Wales have also been known to forbid
students to return to school for 7 days if they have visited urban Victoria. In the
Philippines, college classes were postponed for a week. [221] The Hong Kong
government has announced that all nurseries, kindergartens and primary schools in
Hong Kong would be closed for two weeks starting from 12 June, 2009, after 12
confirm cases in a secondary school on 11 June, 2009.[222][223]

In Guatemala, The Ministry of Health has advised that schools close from June 15 until
June 30 to prevent the spread of the A(H1N1) virus among children.[224]

[edit] Spread in the workplace

The CDC advised sick people to stay home from work, school, or social gatherings and
to generally limit contact with others to avoid infecting them.

[edit] Hygiene

[edit] Airborne transmission

Little data is available on the risk of airborne transmission specific to this particular
virus. Many authorities recommend the use of respirators by health-care workers in the
vicinity of pandemic flu patients, particularly during aerosol generating procedures (e.g.
intubation, chest physiotherapy, bronchoscopy). Masks may be of benefit in "crowded
settings" or for people who are in "close contact" with infected persons, defined as 1
meter or less by the World Health Organization and 6 feet or less by the U.S.
Occupational Safety and Health Administration. In these cases the CDC recommended
respirators classified as N95, but it is unknown whether they would prevent swine flu
infection. [225] According to mask manufacturer 3M, there are no "established exposure
limits for biological agents" such as swine flu virus.

Although Mexican authorities distributed surgical masks to the general public, the UK
Health Protection Agency considered facial masks unnecessary for the general
public[226]. A Los Angeles official[who?] stated that masks may lead to a false sense of
security, may be effective only for a limited time and may be contaminated if taken on
and off. Masks were not generally provided by airport security or airlines. Although the
CDC recommends the use of surgical masks in its guidelines[227], other U.S. officials
stated in May that if the flu virus does in fact reach pandemic proportions, "there won't
be enough face masks to go around."[228]

[edit] Contact with infected surfaces

Infection can be caused by touching a surface contaminated with flu viruses and then
touching the eyes, nose, or mouth.[229] The CDC advised avoiding such contact and
frequent washing of hands with soap and water or with alcohol-based hand sanitizers,
especially after being out in public. Those coughing should use a tissue, dispose of the
tissue, then wash hands right away.[230] Transmission was also reduced by disinfecting
household surfaces with a disinfectant or a diluted bleach solution.[231]

[edit] No danger from pork consumption

The leading international health agencies stressed that the "influenza viruses are not
known to be transmissible to people through eating processed pork or other food
products derived from pigs."[232]

[edit] Airline hygiene precautions

U.S. airlines have made no major changes as of the beginning of June, but continued
standing practices that include looking for passengers with symptoms of flu, measles or
other infections, and rely on in-flight air filters to ensure that aircraft are sanitized. "We
take our guidance from the professionals (such as the CDC)", stated an Air Transport
Association spokesman. The CDC has not recommended that airline crews wear face
masks or disposable overcoats. Alaska Airlines removed all pillows and blankets from
its fleet in late April/early May. [233]

Outside the U.S. however, some airlines have modified hygiene procedures to minimize
travel health risks on international flights. Asian carriers have stepped up cabin
cleaning, installed state-of-the-art air filters and allowed in-flight staff to wear face
masks, with some replacing used pillows, blankets, headset covers and headrest covers,
while others have begun disinfecting the cabins of all aircraft. In China, some airline
flight attendants are required to wear disposable facial masks, gloves and hats and even
disposable overcoats during flights to select destinations. [234]

Singapore has been thermal-screening everyone coming into the country, with
Singapore Airlines giving passengers traveling to the United States health kits that
include a thermometer, masks and antiseptic towels. Its cabin and flight crews are
getting mandatory temperature checks before flights. The government recently
quarantined a passenger who was later found to have the flu along with about 60 other
people on the same flight who were sitting within three rows.[234] A consultant for the
microbiology division at National University Hospital in Singapore, said hygiene
practices such as covering the nose and mouth when sneezing or coughing in confined
areas may be the best way to limit infection and safety measures such as costly air filters
may be of limited use for carriers.[234]

[edit] Vaccination
Main article: 2009 flu pandemic vaccine
Further information: Influenza vaccine#2009-2010 season (Northern Hemisphere)

Preparation of a vaccine against a new strain of flu is nothing new, but limitations on
production capacity, and the cost of production are all significant issues, and there are
concerns that the virus might mutate or undergo reassortment that makes the new
vaccine ineffective.[235][236] However, John Sterling, Editor in Chief of Genetic
Engineering & Biotechnology News, said on June 2, "It can take five or six months to
come up with an entirely novel influenza vaccine. There is a great deal of hope that
biotech and pharma companies might be able to have something ready sooner."[237]
Anne Schuchat, the Immunization Director of the CDC, believes that little pandemic
vaccine will be available by this autumn, even if nothing goes wrong that delays
production. By mid-June, it became clearer that "no one knows whether the newly
commissioned vaccine" will pass critical scientific testing. "Vaccines are not the only
tools we have in the toolbox," said Schuchat. "We have to be ready for the idea that we
may not get a vaccine as soon as we'd like it, or we may not get a vaccine that works as
well as we would like it. Or we might not get a vaccine." U.S. and local health officials
are eyeing the Southern Hemisphere, where the "virus is already on an unstoppable
course" and where it's feared it might combine with the seasonal flu strain and develop
drug resistance.[238] The U.S. goal of pandemic plans is to make 600 million doses in six
months, enough for two doses for each American, according to experts, with an
estimated cost of $8 billion.[112]

The seasonal flu vaccine is not believed to protect against the new strain.[239] The CDC
has considered an "earlier rollout of seasonal vaccine," which usually is made available
in September in the United States, peaking in November. The new vaccine may be
given in a second round of vaccinations rather than being added to the seasonal flu
vaccine or replacing one of its three components with the new H1N1 virus.[240]

[edit] Treatment
Further information: Influenza treatment

[edit] Home treatment remedies

The Mayo Clinic suggested a number of measures to help ease symptoms, including
adequate hydration and rest, soup to ease congestion, and over-the-counter drugs to
relieve pain.[241] The latter would relieve symptoms, but not treat the condition, and runs
the risk of overdose or harm to children if used incorrectly.[242] In general, most patients
were expected to recover without requiring medical attention, with the exception of
individuals with pre-existing or acquired complications.[243]

[edit] Antiviral drugs

According to the CDC, antiviral drugs can be given to treat those who become severely
ill. These antiviral drugs are prescription medicines (pills, liquid or an inhaler) and act
against influenza viruses, including the 2009 pandemic virus. There are two such
medications that are recommended for use against the 2009 H1N1 swine flu virus,
oseltamivir (Tamiflu) and zanamivir (Relenza). The 2009 H1N1 swine flu virus is
resistant to the adamantane antiviral medications, amantadine and rimantadine. The
CDC has noted that as the flu pandemic spreads, antiviral drugs such as oseltamivir
(Tamiflu) and zanamivir (Relenza) might become in short supply. Therefore, the drugs
would be given first to those people who have been hospitalized or are at high risk of
complications. The drugs work best if given within 2 days of becoming ill, but might be
given later if illness became severe or to those at a high risk for complications.

In H3N2 strains, Tamiflu treatment has led to resistance in 0.4% of adult cases and
5.5% of children. Resistant strains usually are less transmissible. Nonetheless resistant
human H1N1 viruses became widely established in previous flu seasons. [244] Marie-
Paule Kiely, WHO vaccine research director, said that it was "almost a given" that the
new strain would undergo reassortment with resistant seasonal flu viruses and acquire
resistance, but it was not yet known at what level resistance would appear.[245]
Simulations suggest that if physicians chose a second effective antiviral such as
zanamivir (Relenza) as first-line treatment in even a few percent of cases, this could
greatly delay the spread of resistant strains. If the virus develops oseltamivir resistance,
the "world‘s Tamiflu stockpiles will be all but worthless," doctors would have to switch
to the more expensive and harder to take, Relenza.[246]

When buying these medications, some agencies warn against buying from online
sources, with WHO estimating that half the drugs sold by online pharmacies without a
physical address are counterfeit.[247] Medical experts were also concerned that people
"racing to grab up antiviral drugs just to feel safe" might eventually lead to the virus
developing drug resistance. Partly as a result, experts suggested the medications should
be reserved for only the very ill or people with severe immune deficiencies.[248]

[edit] Emergency planning
See also: Influenza pandemic#Government preparations for a potential H5N1 pandemic

Emergency preparedness experts suggest that organizations, such as corporations,
should be making plans now in case something big and unexpected happens with the
Swine Flu or other potential pandemic viruses. Kevin Nixon, an emergency planning
expert who has testified before Congress and served on the Disaster Recovery
Workgroup for the Office of Homeland Security, and the Federal Trade Commission,
stresses that private companies "should be hammering out a game plan for who would
do what and where if the government decided to restrict our movements to contain an
outbreak." He states that "companies and employers that have not done so are being
urged to establish a business continuity plan should the government direct state and
local governments to immediately enforce their community containment plans."[249]

Emergency planning would include some of the following: Asking people with
symptoms, and members of an ill person's household, to voluntarily remain at home for
up to 7 days; sending students home from school, including public and private schools
as well as colleges and universities, and recommending out-of-school social distancing;
and recommending social distancing of adults which could include cancelling public
gatherings or changing workplace environments.[249]

Crime risk

In early June, the Australian Crime Commission, in a written public report, warned that
criminals may exploit a swine flu pandemic. They pointed out that illicit markets,
robbery and fraud through false charities were all potential targets for organised crime,
and the emergence of a black market for medicine was also a concern. "Criminal groups
may also seek to infiltrate legitimate markets such as transport, finance and government
sectors to help facilitate criminal activity and confuse the line between their illegal and
legal activities," the report said. It warns of potential robbery and extortion, counterfeit
medicine scams, black markets, charity fraud, welfare fraud and possibly increased
community influence." Industrial drug sites might be targeted for robbery along with
retail chemists.[250]

In late May, the U.S. Food and Drug Administration (FDA) uncovered a "surge of
phony swine flu treatments" available on the Internet. They have reportedly ordered
dozens of Web site operators to stop making fraudulent claims. In the six weeks since
FDA's campaign began the number of new sites selling fake swine flu treatments and
protective devices has plummeted, whereas at the beginning they were seeing as many
as 10 new Web sites a day selling fraudulent products.[251]

         Wikinews has related news: Swine flu cases worldwide top 1,000

[edit] See also
      1918 flu pandemic
      1976 swine flu outbreak
      2009 swine flu outbreak by country
      2009 flu pandemic table
      2009 swine flu outbreak timeline
      GISAID - The Global Initiative on Sharing All Influenza Data
      Health care in Mexico
      Hong Kong Flu (1968–1969)
      Severe acute respiratory syndrome (SARS)

[edit] References
[edit] Sources and notes

   1. ^ a b c d e f g h i j k l m n o p q r s "Influenza A(H1N1) - update 51". World Health
      Organization. 2009-06-19 07:00 GMT. Retrieved on 2009-06-
   2. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al European Centre
      for Disease Prevention and Control: [1] Update:"ECDC SITUATION REPORT
      Update 21 June 2009, 17:00 hours CEST". 2009-06-21.
      pdf. Retrieved on 2009-06-21.
   3. ^ a b Secretariat of Health: Secretaría de Salud - Mexican
      government."COMUNICADO DE PRENSA No. 194" (in Spanish). 2009-06-18.
      09-06-18_4024.html. Retrieved on 2009-06-19.
   4. ^ "Situacion actual de la epidemia" (in Spanish). México, Secretaría de Salud.
      505.pdf. Retrieved on 2009-06-06.
   5. ^ "Mexico confirms 42 deaths of A/H1N1 flu". 2009-05-07.
    yId=200. Retrieved on 2009-05-29. "Cordova said [...] 77 [early deaths] did not
    have usable samples, meaning that they would never be confirmed or ruled out."
6. ^ Sum of state-reported confirmed cases; See US Swine Flu outbreak table for
    more information.
7. ^ Information based on sources cited regarding deaths in the U.S. in the US
    Swine Flu outbreak table.
8. ^ a b Sum of canadian state-reported confirmed cases; See Canadian Swine Flu
    outbreak table for more information.
9. ^ "Epidemiological Alert: Daily reports on the A(H1N1) Influenza situation" (in
    Spanish). Ministry of Health of Argentina. 2009.
10. ^ "Situación de la Influenza A (H1N1)" (in Spanish). Health Ministry. 16-06-
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[edit] Further reading

      Influenza: H1N1 at the Open Directory Project
      Soundararajan, Venkataramanan; et al. (June 2009). "Extrapolating from sequence
       — the 2009 H1N1 'swine' influenza virus". Nature Biotechnology 27 (6): 510-513.
   Smith, Gavin; et al. (2009). "Origins and evolutionary genomics of the 2009 swine-
    origin H1N1 influenza A epidemic". Nature Forthcoming.
   Swine flu: Bihar gears up to meet possible threat
   Official swine flu advice and latest information from the UK National Health
   Swine influenza, at the World Health Organization
   Pan-American Health Organization (PAHO) Swine Influenza portal
   H1N1 Influenza (Flu) portal at the U.S. Centers for Disease Control (CDC)
   Influenza A(H1N1) at the European Centre for Disease Prevention and Control
   International Society for Infectious Diseases PROMED-mail news updates
   U.S. Government swine, avian and pandemic flu portal
   Medical Encyclopedia Medline Plus: Swine Flu
   Swine Flu Outbreak, Influenza Virus Resource Sequences and related resources
    (GenBank, NCBI)
   BioHealthBase Bioinformatics Resource Center Database of influenza genomic
    sequences and related information.
   Human/Swine A/H1N1 Influenza Origins and Evolution Analysis of genetic data
    for the origin and evolution of swine flu virus.
   Swine flu charts and maps Numeric analysis and approximation of current active
   Health-EU Portal Influenza

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