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2009 flu pandemic

 
Wikipedia: 2009 flu pandemic
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Pandemic H1N1/09 Influenza
Classification and external resources

Electron microscope image of the reassorted H1N1 influenza virus. The viruses are ~100 nanometres in diameter.[1]
MedlinePlus 007421
eMedicine article/1673658
MeSH D053118

The 2009 flu pandemic, or swine flu, is a global outbreak of a new strain of influenza A virus subtype H1N1, a type of swine influenza, that was first detected in March and April 2009.[2] The outbreak began in Veracruz, Mexico, with evidence that there had been an ongoing epidemic for months before it was officially recognized as such.[3] The Mexican government closed most of Mexico City's public and private facilities in an attempt to contain the spread of the virus. However the virus continued to spread globally, clinics were overwhelmed by people inflicted, and the World Health Organization (WHO) and US Centers for Disease Control (CDC) stopped counting all cases and focused on tracking major outbreaks. On June 11, 2009, the WHO declared the outbreak a pandemic.[4] As of November 20, 2009 (2009 -11-20), the swine flu virus activity may have peaked in the U.S. and some European countries, while other countries report sharp increases.[5][6]

While only mild symptoms are experienced by the majority of people,[4] some have more severe symptoms. Mild symptoms may include include fever, sore throat, cough, headache, muscle or joint pains, and nausea, vomiting, or diarrhea. Those at risk of a more severe infection include: asthmatics, diabetics,[7] those with obesity, heart disease, the immunocompromised, children with neurodevelopmental conditions,[8] and pregnant women.[9]

In addition, even for persons previously very healthy, a small percentage of patients will develop viral pneumonia. This manifests itself as increased breathing difficulty and typically occurs 3 to 6 days after initial onset of flu symptoms.[10][11]

Similar to other influenza viruses, pandemic H1N1 is typically contracted by person to person transmission through respiratory droplets.[12] Symptoms usually last 4 to 6 days.[13] To avoid spreading the infection, it is recommended that those with symptoms stay home, away from school, work, and crowded places. Those with more severe symptoms or those in an at risk group may benefit from antivirals (oseltamivir or zanamivir).[14] As of November 25, 2009 (2009 -11-25), there are 7,909 confirmed deaths worldwide.

Influenza (Flu)
H1N1 navbox.jpg
Types
Avian (A/H5N1 subtype) · Canine
Equine · Swine (A/H1N1 subtype)
Vaccines
2009 pandemic (Pandemrix)
ACAM-FLU-A · Fluzone · Influvac
Live attenuated (FluMist) · Optaflu
Treatment
Amantadine · Arbidol · Laninamivir
Oseltamivir · Peramivir · Rimantadine
Vitamin D · Zanamivir
Pandemics
2009 · 1968-1969 Hong Kong · 1918
Outbreaks
2008 West Bengal
2007 Bernard Matthews H5N1
2007 Australian equine
2006 H5N1 India · 1976 swine flu
See also
Flu season · Influenza evolution
Influenza research · Influenza-like illness
v • d • e


Contents

Classification

Further information: Pandemic H1N1/09 virus: Nomenclature

The initial outbreak was called the "H1N1 influenza". It is officially called pandemic H1N1/09 virus by the WHO,[15] while the CDC refers to it as "novel influenza A (H1N1)" or "2009 H1N1 flu".[16] In the Netherlands, it was originally called "Pig Flu", but is now called "New Influenza A (H1N1)" by the national health institute, although the media and general population use the name "Mexican Flu". South Korea and Israel briefly considered calling it the "Mexican virus".[17] Later, the South Korean press used "SI", short for "swine influenza". Taiwan suggested the names "H1N1 flu" or "new flu", which most local media adopted.[18] The World Organization for Animal Health proposed the name "North American influenza".[19] The European Commission adopted the term "novel flu virus".[20] The main strain of virus has been termed "A/California/07/2009 (H1N1)" by scientists.[21]

Signs and symptoms

The symptoms of swine flu are similar to other influenzas, and may include a fever, coughing (typically a "dry cough"), headaches, muscle or joint pain, sore throat, chills, fatigue, and runny nose. Diarrhea, vomiting, and neurological problems were also reported in some cases.[22][23] People at higher risk of serious complications include those aged over 65, children younger than 5, children with neurodevelopmental conditions, pregnant women (especially during the third trimester),[10][24] and those 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).[9] Most hospitalizations in the US were people with such underlying conditions, according to the CDC.[25]

A New England Journal of Medicine article on hospitalized United States H1N1 patients from April to mid-June found that 40% had chest X-rays consistent with pneumonia. And if the same pattern holds from the 1957-58 pandemic, then approximately two-thirds of such patients have viral pneumonia and one-third have bacterial pneumonia. It is recommended that these patients receive both antivirals and antibiotics.[26]

A study from Australia and New Zealand estimated that the demand for ICU beds due to viral pneumonia was much higher during the pandemic than in previous influenza seasons.[27] A Canadian study reported that intensive care capacity in Winnipeg, Manitoba was "seriously challenged" at the peak of the outbreak, with full occupancy of all regional ICU beds.[27]

In adults

In adults, shortness of breath, pain in the chest or abdomen, sudden dizziness, or confusion may require 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.[23] If it follows the same pattern as in children, a relapse with high fever may in fact be pneumonia.

Dr. Thomas R. Frieden, Director of the CDC,[28] suggests that people with "underlying conditions" who come down with flu symptoms should consult their doctors first before visiting an "emergency room full of sick people," since it "may actually put them in more danger." This was especially true of pregnant women.[9]

In children

As with the seasonal flu, certain symptoms may require emergency medical attention. In children, signs of respiratory distress include blue lips and skin, dehydration, rapid breathing, excessive sleeping, seizures,[29] and significant irritability including a lack of desire to be held. Although "too early" to tell for certain, so far the swine flu "seems to be taking a heavier toll among chronically ill children than the seasonal flu usually does."[30] Of the children who have died so far, nearly two-thirds had pre-existing nervous system disorders, such as cerebral palsy, muscular dystrophy, or developmental delays. "Children with nerve and muscle problems may be at especially high risk for complications".[30] "In children without chronic health problems, it is a warning sign if they seem to recover from the flu but then relapse with a high fever. The relapse may be bacterial pneumonia, which must be treated with antibiotics."[30] Secondary bacterial infections have been found in 30% of fatal cases for all persons, both children and adults. The most common finding in severe cases has been primary viral pneumonia.[10] Warning signs include difficulty breathing, a crying child who cannot be consoled, or a child who doesn’t wake up, walk, or talk normally.[11]

Researchers in Australia and New Zealand have reaffirmed that infants under the age of 1 year have the highest risk of developing severe illness from swine flu.[27]

Diagnosis

Confirmed diagnosis of pandemic H1N1/09 flu requires testing of a nasopharyngeal, nasal, or oropharyngeal tissue swab from the patient.[31] Real-time RT-PCR is the recommended test as others are unable to differentiate between pandemic H1N1/09 and regular seasonal flu;[31] however, availability of the test is limited.[32] Typical processing time for the test is 2–4 days.[32] Isolation of pandemic H1N1/09 flu virus from a viral culture is also diagnostic of infection, but takes too long to be of practical use (2–10 days);[32] a negative viral culture does not exclude the possibility of infection with pandemic H1N1/09 flu.[31]

However, most people with flu symptoms do not need a test for pandemic H1N1/09 flu specifically, because the test results usually do not affect the recommended course of treatment.[33] The CDC only recommends testing for people who are hospitalized with suspected flu, pregnant women, and people with weakened immune systems.[33]

For the mere diagnosis of influenza and not pandemic H1N1/09 flu specifically, more widely available tests include rapid influenza diagnostic tests (RIDT), which yield results in about 30 minutes, and direct and indirect immunofluorescence assays (DFA and IFA), which take 2–4 hours; DFA and IFA are more sensitive to pandemic H1N1/09 virus than RIDT.[32]

Virus characteristics

Main article: Pandemic H1N1/09 virus

The virus is a novel strain of influenza for which extant vaccines against seasonal flu provide little protection. 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%.[34][35] It was also determined that the strain contained genes from five 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 proteins of the virus are most similar to strains that cause mild symptoms in humans, leading virologist Wendy Barclay to suggest on May 1, 2009 that the initial indications are that the virus was unlikely to cause severe symptoms for most people.[36]

In July 2009, the CDC noted that most infections were mild, similar to seasonal flu, recovery tended to be fairly quick, and deaths to date had been only a fraction of the number of people who die every year from seasonal flu.[citation needed] The 1918 flu epidemic began with a wave of mild cases in the spring, followed by more deadly waves in the autumn, eventually killing hundreds of thousands in the United States.[37] Researchers from the University of Maryland mixed swine flu and seasonal flu and concluded that the swine flu was unlikely to get more lethal.[38]

And, for more regarding the probable or possible history of Novel H1N1, a July 9, 2009, New England Journal of Medicine article states: "H1N2 and other subtypes are descendants of the triple-reassortant swine H3N2 viruses isolated in North America.[39] They have spread in swine hosts around the globe and have been found to infect humans. The segments coding for the neuraminidase and the matrix proteins of the new human H1N1 virus are, however, distantly related to swine viruses isolated in Europe in the early 1990s."[40]

Transmission

Spread of the H1N1 virus is thought to occur in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing by people with influenza. Sometimes people may become infected by touching something – such as a surface or object – with flu viruses on it and then touching their mouth or nose.[41] The basic reproduction number (the average number of other individuals that each infected individual will infect, in a population that has no immunity to the disease) for the 2009 novel H1N1 is estimated to be 1.75.[42]

The H1N1 virus has been transmitted to animals - pigs, turkeys, ferrets, and a household cat.[43][44]

Prevention

See also: Influenza prevention, 2009 flu pandemic vaccine, and Influenza vaccine#2009-2010 season (Northern Hemisphere)

The pandemic is expected to peak by mid-winter in the Northern hemisphere.[45] The CDC recommended that initial vaccine doses should go to priority groups such as pregnant women, people who live with or care for babies under six months old, children six months to four years old and health-care workers.[46] In the UK, the NHS recommended vaccine priority go to people over six months old who were clinically at risk for seasonal flu, pregnant women, and households of people with compromised immunity.[47]

Although it was initially thought that two injections would be required, clinical trials showed that the new vaccine protects adults "with only one dose instead of two", and so the limited vaccine supplies would go twice as far as had been predicted.[48][49] Costs would also be lowered by having a "more efficient vaccine".[48] For children under the age of 10, two administrations of the vaccine, spaced 21 days apart, are recommended.[50][51] The seasonal flu will still require a separate vaccination.[52]

Health officials worldwide were also concerned because the virus was new and could easily mutate and become more virulent, even though most flu symptoms were mild and lasted only a few days without treatment. Officials also urged communities, businesses and individuals to make contingency plans for possible school closures, multiple employee absences for illness, surges of patients in hospitals and other effects of potentially widespread outbreaks.[53]

To combat the virus, the WHO and the US government geared up for a massive vaccination campaign in late 2009, one not seen since Jonas Salk discovered the polio vaccine in 1955.[54]

The Mayo Clinic suggested personal measures to avoid seasonal flu infection were applicable to the 2009 pandemic: vaccination when available, thorough and frequent hand-washing, a balanced diet with fresh fruits and vegetables, whole grains, and lean protein, sufficient sleep, regular exercise, and avoiding crowds.[55] Smoking raises the risk of contracting influenza, as well as producing more severe disease symptoms.[56]

Leading health agencies have stressed that eating properly cooked pork or other food products derived from pigs would not cause flu.[57]

Public health response

See also: 2009 flu pandemic by country
     Deaths     Confirmed cases See also: H1N1 live map, WHO updates

On April 27, 2009, the European Union health commissioner advised Europeans to postpone nonessential travel to the United States or Mexico. This followed the discovery of the first confirmed case in Spain.[58] On May 6, 2009, the Public Health Agency of Canada announced that their National Microbiology Laboratory (NML) had mapped the genetic code of the swine flu virus, the first time that was done.[59] In England, the National Health Service launched a website, the National Pandemic Flu Service,[60] allowing patients to self-assess and get an authorization number for antiviral medication. The system was expected to reduce the burden on general practitioners.[47]

US officials observed that six years of worrying about H5N1 avian flu did much to prepare for the current swine flu outbreak, noting that after H5N1 emerged in Asia, ultimately killing about 60% of the few hundred people infected by it over the years, many countries took steps to try to prevent any similar crisis from spreading further.[61] The CDC and other American governmental agencies[62] used the summer lull to take stock of the United States's response to swine flu and attempt to patch any gaps in the public health safety net before flu season started in early autumn.[63] Preparations included planning a second influenza vaccination program in addition to the one for seasonal influenza, and improving coordination between federal, state, and local governments and private health providers.[63] On October 24, 2009, U.S. President Obama declared swine flu a national emergency, giving Secretary of Health and Human Services Kathleen Sebelius authority to grant waivers to requesting hospitals from usual federal requirements.[64]

On November 2, 2009, at Ukraine's request, the WHO sent a team of nine experts to determine if the same strain of swine flu is responsible for the 70 recent deaths from acute respiratory illness in the country.[65][66] Ukraine has also closed schools and banned public meetings for three weeks.[67][68] As of November 2, 2009 (2009 -11-02), 255,000 cases of flu had been reported in Ukraine, with 170 receiving ICU treatment and the swine flu virus being confirmed for 22 deaths.[69] Nine western provinces have had quarantines imposed to control the disease's spread.[69] Some Ukrainian health officials and medical experts think the crisis has been exaggerated for political reasons in the run up to the January 2010 Ukrainian Presidential race.[70] On November 17, 2009, the WHO issued a statement that there were no significant differences between the pandemic H1N1 strain, and the Ukrainian strains tested.[71]

Vaccines

Main article: 2009 flu pandemic vaccine

As of November 19, 2009 (2009 -11-19), over 65 million doses of vaccine had been administered in over 16 countries; fewer than a dozen cases Guillain-Barre syndrome have been reported post-vaccination. Only a few of these are suspected to be actually related to the H1N1 vaccination, and only temporary illness has been observed.[72] This is in strong contrast to the 1976 swine flu outbreak, where mass vaccinations in the United States caused over 500 cases of Guillain-Barre syndrome and led to 25 deaths.[73]

There are safety concerns for people who are allergic to eggs because the viruses for the vaccine are grown in chicken-egg-based cultures. People with egg allergies might be able to receive the vaccine, after consultation with their physician, in graded doses in a careful and controlled environment.[74] A vaccine manufactured by Baxter is made without using eggs, but requires two doses three weeks apart to produce immunity.[75]

Infection control

Travel precautions
Flu inspection on flight arriving in China
Thermal imaging camera & screen, photographed in an airport terminal in Greece. Thermal imaging can detect elevated body temperature, one of the signs of swine flu.

On May 7, 2009 the WHO stated that containment was not a feasible and that countries should focus on mitigating the effect of the virus. It did not recommend closing borders or restricting travel.[76] On April 26, 2009, the Chinese government announced that visitors returning from flu-affected areas who experienced flu-like symptoms within two weeks would be quarantined.[77] On May 2, 2009, China suspended flights from Tijuana to Shanghai.[78]

The president of the Association of Flight Attendants told members of a US Congressional subcommittee that all flight attendants should be given training in how to handle a person with flu and help in communicating to passengers the importance of keeping clean hands.[79] She also said that flight attendants need to be provided gloves and facemasks to deal with flu-stricken passengers.[79] Lahey Clinic vice chairman of emergency medicine and Tufts University assistant professor of emergency medicine Mark Gendreau adds that airlines should also ensure that passenger cabins are always properly ventilated, including during flight delays in which passengers are kept aboard the plane. But he also adds that although the aviation industry in the US, along with the CDC, have tried to reassure passengers that air travel is safe, they have so far done too little to try to limit infection risks.[79]

US airlines made no major changes as of the beginning of June 2009, but continued standing practices that included looking for passengers with symptoms of flu, measles, or other infections, and relying on in-flight air filters to ensure that aircraft were sanitized.[80] Masks were not generally provided by airlines and the CDC did not recommend that airline crews wear them.[80] Some non-US airlines, mostly Asian ones, including Singapore Airlines, China Eastern Airlines, China Southern Airlines, Cathay Pacific, and Mexicana Airlines, took measures such as stepping up cabin cleaning, installing state-of-the-art air filters, and allowing in-flight staff to wear face masks.[80]

Schools
Ambox globe content.svg
 The examples and perspective in this article may not represent a worldwide view of the subject. Please improve this article and discuss the issue on the talk page. (October 2009)

The swine flu outbreak has led to numerous precautionary school closures in several countries. Rather than closing schools, the CDC recommended in August that students and school workers with flu symptoms should stay home for either seven days total, or until 24 hours after symptoms subside—whichever is longer.[81] The CDC also recommended that colleges should consider suspending fall 2009 classes if the virus begins to cause severe illness in a significantly larger share of students than last spring. They have additionally urged schools to suspend any rules, including penalizing late papers or missed classes, or requiring a doctor's note, to enforce "self-isolation" and prevent students from venturing out while ill;[82] schools were advised to set aside a room for people developing flu-like symptoms while they wait to go home and that surgical masks be used for ill students or staff and those caring for them.[83]

In California, school districts and universities are on alert and working with health officials to launch education campaigns. Many planned to stockpile medical supplies and discuss worst-case scenarios, including plans to provide lessons and meals for low-income children in case elementary and secondary schools close.[84] University of California campuses were stockpiling supplies, from paper masks and hand sanitizer to food and water.[84] To help prepare for contingencies, University of Maryland School of Medicine professor of pediatrics James C. King Jr. suggests that every county should create an "influenza action team" to be run by the local health department, parents, and school administrators.[85] As of 28 October 2009 (2009 -10-28), about 600 Schools in the United States have been temporarily closed, affecting over 126,000 students in 19 states.[86]

US government officials are especially concerned about schools because the swine flu virus appears to disproportionately affect young and school-age people, between ages 6 months to 24 years of age, making them one of the top priority groups when it comes to the new vaccine. They state that the most important actions are to encourage and facilitate good hand washing and covering coughs and sneezes, flu vaccinations for people at risk; and to separate sick people from healthy people as soon as possible.[87]

In Ukraine, the government closed all schools and universities for 3 weeks and restricted public gatherings to control the spread of swine flu. International schools, such as the International School of Bucharest, the International School of Zagreb and the International School of Prague and the International school in Riga have all been closed for extended periods of time. The American School of Warsaw remains open, however cases of symptoms have been reported and a large percentage of students are already missing school due to the normal flu epidemic and are therefore at greater risk of getting swine flu.[67]

Workplace
Ambox globe content.svg
 The examples and perspective in this article may not represent a worldwide view of the subject. Please improve this article and discuss the issue on the talk page. (October 2009)

The US Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), with input from the US Department of Homeland Security (DHS), have developed updated guidance[88] and a video for employers to use as they develop or review and update plans to respond to swine flu now and during the upcoming fall and winter influenza season. The guidance states that employers should consider and communicate their objectives, which may include reducing transmission among staff, protecting people who are at increased risk of influenza related complications from getting infected with influenza, maintaining business operations, and minimizing adverse effects on other entities in their supply chains.[88]

The CDC estimates that as much as 40% of the workforce, in a worst-case scenario, might be unable to work at the peak of the pandemic due to the need for many healthy adults to stay home and care for an ill family member,[89] and advising that individuals should have steps in place should a workplace close down or a situation arise that requires working from home.[90] The CDC further advises that persons in the workplace should stay home sick for seven days after getting the flu, or 24 hours after symptoms end, whichever is longer.[81] In the UK, the Health and Safety Executive (HSE) has also issued general guidance for employers.[91]

Facial masks

The CDC does not recommend use of face masks or respirators in non-health care settings, such as schools, workplaces, or public places, with a few exceptions: people who are ill with the virus should consider wearing one when around other people, and people who are at risk for severe illness while caring for someone with the flu.[92] Health workers who are at risk of contracting pandemic flu are advised to wear a surgical mask to either United States standard NIOSH N95, or European standard EN 149 FFP3.[citation needed] There is general uncertainty among health professionals about the value of wearing either facial masks or more expensive respirators to prevent infection. Dr. Laurene Mascola, Los Angeles County Department of Public Health's director of acute communicable disease control, stated that "masks may give people a false sense of security," and associate professor of medicine at the USC Keck School of Medicine Dr. Paul Holtom stressed that masks should not replace other standard precautions.[93] Masks may benefit people in close contact with infected persons but it was unknown whether they prevent swine flu infection.[93] Yukihiro Nishiyama, professor of virology at Nagoya University's School of Medicine, commented that the masks are "better than nothing, but it's hard to completely block out an airborne virus since it can easily slip through the gaps".[94] According to mask manufacturer 3M, masks will filter out particles in industrial settings, but "there are no established exposure limits for biological agents such as swine flu virus."[93] 3M gained an additional estimated revenue of $80–100 million 2009 in the third-quarter of 2009 from sales of flu prevention products, including face masks, and its face mask manufacturing plants were being run around the clock, with plant expansions being planned.[95]

Despite the lack of evidence of effectiveness, the use of such masks is common in Asia.[94][96] As cases of swine flu were reported in South Korea in April, sales of face masks in the country increased 24% on a year-on-year basis.[97] In Hong Kong, Secretary for Food and Health York Chow said his government has no plans to require riders of public transportation to wear face masks.[98] Masks are particularly popular in Japan, where cleanliness and hygiene are highly valued and where etiquette obligates those who are sick to wear masks to avoid their spreading disease; they are even available in a variety of styles, including high fashion versions.[94] In May 2009, due to high demand, some drug stores in Japan ran out of face masks, even though the country has 42 different manufacturers of them,[94] prompting some to fashion improvised face masks out of other materials; the city of Tatsuno, Hyōgo went so far as to post instructions on creating such a mask on its official website.[99][100] One mask maker reported sales rising sevenfold year-on-year.[94] In response, Shanghai, Tianjin, and Guangdong Province donated masks to Osaka, Kobe, and Hyōgo Prefecture, respectively.[101] Taiwan also donated 200,000 masks to Osaka and Hyogo.[102]

Quarantine
Turkish H1N1 control

Countries have begun quarantining or have threatened to quarantine foreign visitors suspected of having or being in contact with others who may have been infected. In May, the Chinese government confined 21 US students and three teachers to their hotel rooms.[103] As a result, the US State Department issued a travel alert about China's anti-flu measures and was warning travelers about traveling to China if ill.[104] In Hong Kong, an entire hotel was quarantined with 240 guests;[105] Australia ordered a cruise ship with 2,000 passengers to stay at sea because of a swine flu threat.[106] Egyptian Muslims who went on the annual pilgrimage to Mecca risked being quarantined upon their return.[107] Russia and Taiwan said they would quarantine visitors with fevers who come from areas where the flu is present.[108] Japan quarantined 47 airline passengers in a hotel for a week in mid-May,[109] then in mid-June India suggested pre-screening "outbound" passengers from countries thought to have a high rate of infection.[110]

Pigs and food safety
Main article: 2009 flu pandemic actions concerning pigs

The pandemic virus is a type of swine influenza, derived originally from a strain that lived in pigs and this origin gave rise to the common name of "swine flu". This term is widely used by mass media. The virus has been found in American[111] and Canadian[112] hogs, as well as in hogs in Northern Ireland, Argentina, and Norway.[113] However, despite its origin in pigs, this strain is transmitted between people and not from swine to people.[3] The United States Secretary of Agriculture made clear that despite its common name being "swine flu", there is no risk of contracting flu from eating cooked pork products.[114] Nevertheless, on April 27, Azerbaijan imposed a ban on the importation of animal husbandry products from America.[115] The Indonesian government also halted the importation of pigs and initiated the examination of 9 million pigs in Indonesia.[116] The Egyptian government ordered the slaughter of all pigs in Egypt on April 29, 2009.[117]

Treatment

Further information: Influenza treatment

A number of methods have been recommended to help ease symptoms, including adequate liquid intake and rest.[118] Over-the-counters pain killers such as acetaminophen and ibuprofen are also useful to improve symptoms. These measure however do not kill the virus.[119] Most people recover without medical attention, although those with pre-existing or underlying medical conditions are more prone to complications and might benefit from further treatments.[120]

Antivirals

People in at-risk groups should be treated with antivirals (oseltamivir or zanamivir) as soon as possible when they have flu symptoms. The at risk groups includes pregnant women, children under 2 years old, and people with ‘underlying conditions' such as respiratory problems.[14] People who are not from the at-risk group who have persistent or rapidly worsening symptoms should also be treated with antivirals. These symptoms include difficulty breathing and a high fever that lasts beyond 3 days. People who have developed pneumonia should be given both antivirals and antibiotics, as in many severe cases of H1N1-caused illness, bacterial infection develops.[121] Antivirals are most useful if given within 48 hours of the start of symptoms and may improve outcomes in hospitalized patients.[122] In those beyond 48 hours who are moderately or severely ill antiviral may still be beneficial.[12] If oseltamivir (Tamiflu) is unavailable or cannot be used zanamivir (Relenza) is recommended as a substitute.[14][123]

To help avoid shortages of these drugs, the CDC recommended oseltamivir treatment primarily for people hospitalized with pandemic flu; people at risk of serious flu complications due to underlying medical conditions; and patients at risk of serious flu complications. The CDC warned that the indiscriminate use of antiviral medications to prevent and treat influenza could ease the way for drug-resistant strains to emerge which would make the fight against the pandemic that much harder. In addition, a British report found that people often failed to complete a full course of the drug or took the medication when not needed.[124]

Side effects

Both medications have known side effects, including lightheadedness, nausea, vomiting, loss of appetite, and trouble breathing. Children were reported to be at increased risk of self-injury and confusion after taking oseltamivir.[118] The WHO warns against buying antiviral medications from online sources, and estimates that half the drugs sold by online pharmacies without a physical address are counterfeit.[125]

Resistance

An October 3, 2009, CDC weekly report states that over two thousand virus isolates of type 2009 Influenza A (H1N1) have been tested for resistance to oseltamivir (Tamiflu), and only twelve have been found to be resistant (less than 1%). Over five hundred isolates have been tested for resistance to antivirals of the category adamantanes, and all have been found to be resistant. Conversely, for Seasonal Influenza A (H1N1), almost all were resistant to oseltamivir (Tamiflu), but only seven out of 1,157 were resistant to adamantanes.[126] And thus, a physician needs to make a good judgment call regarding which virus is more likely to be circulating, as well as monitoring a patient’s progress and perhaps adjusting medication as he or she goes along. None of these isolates, neither Seasonal nor 2009 Influenza A (H1N1), are resistant to zanamivir (Relenza) for the time being.[126]

As of 13 November 2009 (2009 -11-13), there was only sporadic resistance of H1N1 to oseltamivir. Of over 10,000 isolates of pandemic H1N1 that were tested only 52 were resistant to oseltamivir. These however remained sensitive to zanamivir.[127]

Peramivir

Peramivir is an experimental antiviral drug that acts as a neuraminidase inhibitor.[128] In October 2009, it was reported that Peramivir had been effective in treating serious cases of swine flu. On October 23, the U.S. Food and Drug Administration (FDA) issued an Emergency Use Authorization for Peramivir, allowing the use of the drug in intravenous form for hospitalized patients only in cases where the other available methods of treatment are ineffective or unavailable;[129] for instance, if Tamiflu resistance develops and a person is unable to take Relenza via the inhaled route. Peramivir is currently the only intravenous option for treating swine flu.

Epidemiology

Further information: 2009 flu pandemic timeline, 2009 flu pandemic tables, and 2009 flu pandemic by country
2009 flu pandemic data
Area Confirmed
deaths		 Increase in
last 7 days
Worldwide (total) 7,909 +742 (9%)†
European Union and EFTA 714 +171 (24%)
Other European countries
and Central Asia		 91 +24 (26%)
Mediterranean and Middle East 539 +145 (27%)
Africa 108 +0 (0%)
North America 2,088 +322 (15%)
Central America and Caribbean 174 +4 (2%)
South America 2,780 +20 (1%)†
Northeast Asia and South Asia 833 +54 (6%)
Southeast Asia 367 +1 (0%)
Australia and Pacific 215 +1 (0%)
Source: ECDC – November 25, 2009[130]
Further information: Cases and deaths by country
†.^ The numbers for Brazil are not reported on a regular weekly basis.
Thus, these figures may not accurately reflect the real situation.
 v • d • e 

While it is not known precisely where or when the virus originated,[131][132] analyses in scientific journals have suggested that the H1N1 strain responsible for the current outbreak first evolved in September 2008 and circulated amongst humans for several months before being formally recognized and identified as a novel strain of influenza.[131][133]

Mexico

Further information: 2009 flu pandemic in Mexico

The virus was first reported in two US children in March 2009, but health officials have reported that it apparently infected people as early as January 2009 in Mexico.[134] The outbreak was first detected in Mexico City on March 18, 2009;[135] immediately after the outbreak was officially announced, Mexico requested material support from the US, and within days of the outbreak Mexico City was "effectively shut down".[136] Some countries canceled flights to Mexico while others halted trade. Calls to close the border to contain the spread were rejected.[136] Mexico already had hundreds of cases before the outbreak was officially recognized, and was therefore in the midst of a "silent epidemic". As a result, Mexico was reporting only the most serious cases, possibly leading to a skewed initial estimate of the case fatality rate.[135]

United States

Further information: 2009 flu pandemic in the United States

The new strain was first identified by the CDC in two children, neither of whom had been in contact with pigs. The first case, from San Diego County, California, was confirmed from clinical specimens (nasopharyngeal swab) examined by the CDC on April 14, 2009. A second case, from nearby Imperial County, California, was confirmed on April 17. The patient in the first confirmed case had flu symptoms including fever and cough on clinical exam on March 30, and the second on March 28.[137]

The first confirmed swine flu death occurred at Texas Children's Hospital in Houston, Texas.[138]

Data reporting and accuracy

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

The initial outbreak received a week of near-constant media attention. 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. Inaccuracies could also be caused by authorities in different countries looking at differing population groups. Furthermore, countries with poor health care systems and older laboratory facilities may take longer to identify or report cases.[139] "...[E]ven in developed countries the [numbers of flu deaths] are uncertain, because medical authorities don't usually verify who actually died of influenza and who died of a flu-like illness."[140] Dr. Joseph S. Bresee (the CDC flu division's epidemiology chief) and Dr. Michael T. Osterholm (director of the Center for Infectious Disease Research) have pointed out that millions of people have had swine flu, usually in a mild form, so the numbers of laboratory-confirmed cases were actually meaningless, and in July 2009 the WHO stopped keeping count of individual cases and focused more on major outbreaks.[141]

History

Annual influenza epidemics are estimated to affect 5–15% of the global population. Although most cases are mild, these epidemics still cause severe illness in 3–5 million people and 250,000–500,000 deaths worldwide.[142] On average 41,400 people die each year in the United States based on data collected between 1979 and 2001.[143] In industrialized countries, severe illness and deaths occur mainly in the high-risk populations of infants, the elderly, and chronically ill patients,[142] although the swine flu outbreak (as well as the 1918 Spanish flu) differs in its tendency to affect younger, healthier people.[144]

In addition to these annual epidemics, Influenza A virus strains caused three global pandemics during the 20th century: the Spanish flu in 1918, Asian flu in 1957, and Hong Kong flu in 1968–69. These virus strains had undergone major genetic changes for which the population did not possess significant immunity.[145] Recent genetic analysis has revealed that three-quarters, or six out of the eight genetic segments of the 2009 flu pandemic strain arose from the North American swine flu strains circulating since 1998, when a new strain was first identified on a factory farm in North Carolina, and which was the first-ever reported triple-hybrid flu virus.[146]

The great majority of deaths in the 1918 flu pandemic were the result of secondary bacterial pneumonia. The influenza virus damaged the lining of the bronchial tubes and lungs of victims, allowing common bacteria from the nose and throat to infect their lungs. Subsequent pandemics have had many fewer fatalities due to the development of antibiotic medicines that can treat pneumonia.[147]

20th century flu pandemics
Pandemic Year Influenza virus type People infected (approx) Deaths worldwide (est.) Case fatality rate
Spanish flu 1918–19 A/H1N1[148] 33% (500 million)[149] 20 to 100 million[150][151][152] >2.5%[153]
Asian flu 1956–58 A/H2N2[148]  ? 2 million[152] <0.1%[153]
Hong Kong flu 1968–69 A/H3N2[148]  ? 1 million[152] <0.1%[153]
Seasonal flu Every year mainly A/H3N2, A/H1N1, and B 5–15% (340 million – 1 billion)[154] 250,000–500,000 per year[142] <0.1%[155]
Mexican flu 2009 Pandemic H1N1/09 >526,060[6] 7,909 (confirmed; ECDC)[130]
≥6,770 (WHO)[6]		  ?
      Not necessarily pandemic, but included for comparison purposes.

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.[145] The world has been at an increased level of alert since the SARS epidemic in Southeast Asia (caused by the SARS coronavirus).[156] 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.[157]

People who contracted flu before 1957 appeared to have some immunity to swine flu. Dr. Daniel Jernigan of the CDC has stated: "Tests on blood serum from older people showed that they had antibodies that attacked the new virus [...] That does not mean that everyone over 52 is immune, since Americans and Mexicans older than that have died of the new flu."[158]

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