Jump to content

2009 swine flu pandemic

From Wikipedia, the free encyclopedia

This is an old revision of this page, as edited by Tobixen (talk | contribs) at 23:32, 27 April 2009 (Norway). The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Template:WebSlice-begin Template:2009 swine flu outbreak table Template:WebSlice-end The 2009 swine flu outbreak is the spread of a new strain of H1N1 influenza virus that was first detected by public health agencies in March 2009. Local outbreaks of influenza-like illness were detected in three areas of Mexico, but the presence of this new strain was not clinically discovered for a month. Following this discovery in the states of Texas and California, its presence was swiftly confirmed in the local outbreaks in Mexico, and within days isolated cases elsewhere in the Northern Hemisphere were also identified. By April 27, the new strain was confirmed in Canada, Spain, and the United Kingdom and suspected in many other nations, including New Zealand, with over 2,400 candidate cases, prompting the WHO to raise their pandemic alert level to 4.[1][2]

The new strain is an apparent reassortment of several strains of influenza A virus subtype H1N1, including a strain endemic in humans and two strains endemic in pigs, as well as an avian influenza.[3] Reassortment is common in influenza viruses, due to the segmental structure of their genome. This particular reassortment is consistent with a transmission of swine influenza from pig to human (a zoonosis) combined with the mixing of two viral infections in the same person (superinfection).[citation needed]

In April both the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) expressed serious concerns about this novel strain: Because it apparently transmits from human to human, and has had a relatively high mortality rate (albeit only in Mexico), it has the potential to become a flu pandemic.[4] On April 25, 2009, the WHO determined the situation to be a formal "public health emergency of international concern", with knowledge lacking in regard to "the clinical features, epidemiology, and virology of reported cases and the appropriate responses".[5] Government health agencies around the world also expressed concerns over the outbreak and are monitoring the situation closely.

As of April 26, 2009, Mexico City schools, universities, and all public events remained closed or suspended[6] while other schools in the U.S. closed due to confirmed cases in students.[7][8] On April 27, 2009, Mexican government officials announced the first nationwide shut down of schools in history.[9][10]

Background

Prior influenza season

Prior to the outbreak, the Northern Hemisphere winter of 2008–2009 had been a comparatively mild season for flu infections, which typically cause 250,000–500,000 deaths worldwide yearly, mostly in the elderly, the very young, and persons with chronic illness.[11] Up to April 8, 2009, the CDC had reported the deaths of 43 children from seasonal flu, compared to 68 in the previous flu season.[12] The improvement was attributed in part to an improved Northern Hemisphere winter of 2008–2009 seasonal flu vaccine, for which a rare decision had been made to update all three strains (H1, H3, and B) simultaneously, which ultimately yielded a very good match to the strains of H1N1 and H3N2 which eventually circulated. (This followed the poor performance of the 2007–2008 vaccine, which offered only 2–20% protection rather than the 70–90% achieved in some years.) The improvement was also attributed to new recommendations including the vaccination of people 5–18 years of age, who potentially act as "super-spreaders" due to failure to take precautions such as hand-washing.[13][14]

Furthermore, from December 2005 through February 2009, a total of twelve human infections with swine influenza were reported from ten states in the USA.[15]

Initial outbreak

  Confirmed cases followed by death
  Confirmed cases
  Unconfirmed or suspected cases
See also: Live map of swineflu, H1N1 live map

The outbreak was first detected in Mexico City, where surveillance began picking up a surge in cases of Influenza like illness (ILI) starting March 18.[16] The surge was assumed by Mexican authorities to be "late-season flu" (which usually coincides with a mild Influenzavirus B peak[17]) until April 21,[18][19] when a CDC alert concerning two isolated cases of a novel swine flu was reported in the media.[20] The first two cases identified (and confirmed) as swine flu were two children living in the United States, in San Diego County and Imperial County, California, who became ill on March 28 and 30.[21] This new strain was promptly confirmed in Mexico, connecting the new strain to the ongoing outbreak of ILI. The first deadly case seems to go back to April 13, where it is believed that the first case was in a woman from Oaxaca.[22] Some samples were sent to the US based CDC on April 18.[23] News of the connection was broadcast live in Mexico on April 23, 2009.

In March and April 2009, over 1000 cases of suspected swine flu in humans were detected in Mexico and the southwestern United States. The strain appears to be unusually lethal in Mexico, causing 149 deaths (20 confirmed) so far, mostly in Mexico City.[24] There have also been cases reported in the states of San Luis Potosí, Hidalgo, Querétaro and Mexico State, all in central Mexico;[25] Some cases in Mexico and the United States have been confirmed by the World Health Organization to be a never-before-seen strain of H1N1.[16][26] The Mexican fatalities are mainly young adults of 25 to 45, a hallmark of pandemic flu.[3][27] A new swine flu strain was confirmed in 16 of the deaths and at least 100 others were being tested as of April 24, 2009.[28] Mexican Health Minister José Ángel Córdova on April 24, said "We’re dealing with a new flu virus that constitutes a respiratory epidemic that so far is controllable."[25]

The origins of the new virus strain remain unknown. One theory is that Asian and European strains traveled to Mexico in migratory birds or in people, then combined with North American strains in Mexican pig factory farms before jumping over to farm workers.[29] The first evidence of abnormal influenza patterns in Mexico arose when Notimex, a Mexican newswire, reported on April 5 that Mexican health officials had taken sanitary measures in the rural towns of Perote, Quechulá and Xaltepec due to the spread of a disease affecting 60% of the population and with symptoms similar to those associated with the influenza virus.[30] The Mexican health agency acknowledged that the original disease vector of the virus may have been flies multiplying in manure lagoons of pig farms near Perote, Veracruz, owned by Granjas Carroll,[31] a subsidiary of Smithfield Foods.[32] Smithfield Foods retorted that that it had found no clinical signs or symptoms of the presence of swine influenza in the company's swine herd, or its employees at its joint ventures in Mexico, and that it routinely administers influenza virus vaccination to their swine herds and conducts monthly testing for the presence of swine influenza.[33]

Genetics and effects

Dr. Anne Schuchat, interim Deputy Director for CDC Science and Public Health, said that the American cases were found to be made up of genetic elements from four different flu viruses – North American swine influenza, North American avian influenza, human influenza, and swine influenza virus typically found in Asia and Europe – "an unusually mongrelised mix of genetic sequences."[34] Pigs have been shown to act as a potential "mixing vessel" in which reassortment can occur between flu viruses of several species.[35][36] This new strain appears to be a result of reassortment of human influenza and swine influenza viruses, presumably due to superinfection in an individual human. Influenza viruses readily undergo reassortment because their genome is packaged in 8 pieces (see Orthomyxoviridae).

Director Schuchat said that the virus was resistant to amantadine and rimantadine, but susceptible to oseltamivir (Tamiflu) and zanamivir (Relenza).[37][38][39][40]

Several complete genome sequences for U.S. flu cases were rapidly made available through the Global Initiative on Sharing Avian Influenza Data (GISAID).[41][42] Preliminary genetic characterization found that the hemagglutinin (HA) gene was similar to that of swine flu viruses present in U.S. pigs since 1999, but the neuraminidase (NA) and matrix protein (M) genes resembled versions present in European swine flu isolates. The six genes from American swine flu are themselves mixtures of swine flu, bird flu, and human flu viruses.[43][44] While viruses with this genetic makeup had not previously been found to be circulating in humans or pigs, there is no formal national surveillance system to determine what viruses are circulating in pigs in the U.S.[45] The seasonal influenza strain H1N1 vaccine is thought to be unlikely to provide protection.[46]

Main symptoms of swine flu in humans.[47]

In an interview on April 24, acting CDC director Richard Bessar said that it was still not understood why the American cases were primarily mild disease while the Mexican cases had led to multiple deaths. However, research on previous pandemic strains have suggested that mortality can vary widely between different countries, with mortality being concentrated in the developing world.[48] Differences in the viruses or co-infection are also being considered as possible causes. Only fourteen samples from Mexico had been tested by the CDC, with seven found to match the American strain. He said that the virus had likely passed through several cycles of infection with no known linkages between patients in Texas and California, and that containment of the virus is "not very likely".[49][50] The U.S. embassy reported that a CDC investigative team had arrived in Mexico City on April 25 to work with Mexican counterparts to study the virus.[18]

According to Mike Stobbe of the Associated Press:

A big question is: Just how deadly is the virus in Mexico?

The seasonal flu tends to kill just a fraction of 1% of those infected.

In Mexico, about 70 deaths out of roughly 1,000 cases represents a fatality rate of about 7%. The Spanish flu pandemic of 1918, which killed an estimated 50 million worldwide, had a fatality rate of about 2.5%.

The Mexican rate sounds terrifying. But it’s possible that far more than 1,000 people have been infected with the virus and that many had few if any symptoms, said Dr. Michael Osterholm, a prominent pandemic expert at the University of Minnesota. U.S. health officials echoed him.[51]

Pandemic concern

The U.S. Centers for Disease Control (CDC) and the World Health Organization (WHO) are concerned that this outbreak may become a pandemic, for the following reasons.[52]

New strain
The virus is a new strain of influenza, from which human populations have not been vaccinated or naturally immunized.[53]
Widespread human transmission
The virus appeared to infect by human-to-human transmission. Investigations of infected patients indicated no direct contact with swine, such as at a farm or agricultural fair.[26] The strain was later confirmed to have been transmitted between humans.[54] In contrast, for example, disease transmission in the last severe human outbreak of influenza, the bird flu that peaked in 2006, was determined to be almost entirely from direct contact between humans and birds.[55]
Virulence
The virus has produced severe disease in Mexico, and some deaths. Furthermore, in Mexico (but not in the United States) the illness has primarily struck young, healthy adults, much like the deadly Spanish Flu of 1918, possibly because of the phenomenon known as cytokine storm.[56] Most other influenza strains produce the worst symptoms in young children, elderly adults, and others with weaker immune systems.[26][57]
Lack of data
That other factors are still somewhat unknown, such as transmission rates and patterns and effectiveness of current influenza treatments, combined with the unpredictability of influenza strains, means that reliable forecasts cannot be made.[5]

As noted, predicting the size and severity of influenza outbreaks is a very inexact science. The U.S. government was famously wrong in predicting, in 1976, a swine flu pandemic that never materialized.[58]

Prevention and treatment

File:HolidaySnap2008.jpg
Train commuters in Mexico City wearing surgical masks.

Recommendations to prevent infection by the virus consist of the standard personal precautions against influenza. This includes frequent washing of hands with soap and water or with alcohol-based hand sanitizers, especially after being out in public. People should avoid touching their mouth, nose or eyes with their hands unless they've washed their hands. If people do cough, they should either cough into a tissue and throw it in the garbage immediately or, if they cough in their hand, they should wash their hands immediately.[59]

Many countries confirmed that inbound international passengers will be screened. Typical airport health screening involves asking passengers which countries they have visited and checking whether they feel or look particularly unwell. Thermographic equipment was put into use at a number of airports to screen passengers. In the USA, two confirmed cases were detected through their border infectious disease surveillance.[60] A number of countries advised against travel to known affected regions.

The previously recommended influenza vaccines for the southern and northern hemispheres, including that for the 2009/2010 flu season, are ineffective against the new strain.[61] Current development, large-scale manufacturing, distribution and delivery of a new vaccine takes several months.[60]

U.S.-based medical product company Baxter International has requested a virus sample from the WHO in order to begin development of a new vaccine.[62] Baxter has patented a cell-based technology that may allow the company to develop a vaccine in half the time it usually takes, possibly cutting development time from six months to three.[63]

Of the available antiviral treatments for influenza, the WHO stated that the viruses obtained from the human cases with swine influenza in the United States were sensitive to oseltamivir (Tamiflu)[64] and zanamivir (Relenza) but resistant to amantadine and remantadine.[65] Tamiflu and Relenza also have a preventative effect against Influenzavirus A.[66]

On April 27, the CDC recommended the use of Tamiflu and Relenza for both treatment and prevention of the new strain.[67]

Roche and the US government have extended the shelf-life of stock-piled Tamiflu from the original five years to seven years because studies indicated that the medication continues to maintain its effectiveness.[68]

Some physicians in the US are recommending the use of masks when in public.[69] The purpose of a face mask is to effectively cover a person's mouth and nose so that if a person is around someone who is infected, there is a decreased likelihood of transmission. Recommendations to protect against the avian flu indicated that using a face mask with a rating of N99, N100 or P100 in the United States or a rating of FFP3 in Europe should be effective in protecting against transmission.[70] While face masks with these ratings provide 99% or greater efficiency in protecting against flu transmission, N95 or FFP2 face masks provide about 94% efficiency.[71] N95 and FFP2 rated face masks may therefore also be effective.

However, in the United Kingdom, Health Secretary Alan Johnson told MPs on April 27 that, "Although we are aware that facemasks are being given out to the public in Mexico, the available scientific evidence does not support the general wearing of facemasks by those who are not ill, whilst going about their normal activities."[72]

UN World Health Organization

Congruent WHO and U.S. Government Pandemic Response Charts.

The World Health Organization (WHO) saw no need at this point to issue travel advisories warning travellers not to go to parts of Mexico or the United States. The spokesperson said that the situation might change "depending on what the situation in the field is".[73] WHO Director-General Dr. Margaret Chan also said that it was too premature to issue such recommendations without better analysis and understanding of the situation at this stage.[74]

In a statement, the WHO said "Because there are human cases associated with an animal influenza virus, and because of the geographical spread of multiple community outbreaks, plus the somewhat unusual age groups affected, these events are of high concern" and "WHO acknowledges the United States and Mexico for their proactive reporting and their collaboration with WHO and will continue to work with Member States to further characterize the outbreak".[26]

The WHO established the Emergency Committee of the International Health Regulations for emergency discussions to assess the situation and to formulate appropriate responses, and to provide guidance and advice to the Director-General.[75] The first meeting of the committee was held on April 25 in Geneva.[5]

Before the first meeting, WHO Director-General Margaret Chan said that the Emergency Committee could make recommendations including whether to change the pandemic alert level or not.[73][76]

The WHO decided not to raise the level of the worldwide pandemic alert after the first meeting.[77] A Phase 3 alert means that a new virus has been confirmed but there is no or limited evidence of human-to-human transmission - insufficient to sustain community-level outbreaks. The Phase 3 alert was initially set due to the avian flu.[78][79][80] (Phase 4, "Sustained Human to Human Transmission," entails community-wide outbreaks; Phases 5/6, "Widespread Human Infection," entails human-to-human transmission in at least two countries in one WHO region; Phase 6 is a global pandemic proper.)[81] On April 27, 2009, the WHO raised the pandemic alert level to 4.[82]

The Emergency Committee "identified a number of gaps in knowledge about the clinical features, epidemiology, and virology of reported cases and the appropriate responses", and on its advice, the WHO advised "that all countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia".[5]

Cases and responses by nation

Asia

China and Taiwan

The General Administration of Quality Supervision, Inspection and Quarantine (AQSIQ) of China issued an emergency notice on the evening of 26 April that visitors returning from flu-affected areas who experienced flu-like symptoms within two weeks would be quarantined.[83] The Ministry of Health has started prevention measures and initiated cooperation with the WHO and the relevant departments of the governments of Mexico and the U.S. to help contain the outbreak. According to Wang Jing of the China Inspection and Quarantine Science Research Institute, the measures already in place in China against bird flu are sufficient for this new disease.[84]

Hong Kong and Taiwan said visitors who came back from affected areas with fevers would be quarantined.[85]

Japan

The Ministry of Agriculture, Forestry and Fisheries of Japan instructed animal quarantine offices across Japan to examine any live pigs being brought into Japan to make sure they are not infected with the influenza.[86] Japanese Agriculture Minister Shigeru Ishiba appeared on television to reassure customers that it was safe to eat pork.[85] The Japanese farm ministry said that it would not ask for restrictions on pork imports because the virus was unlikely to turn up in pork, and would be killed by cooking.[87]

Malaysia

According to the Malaysian Health Ministry, health screenings will be carried out on passengers traveling to and from Mexico beginning on April 17.[88] The Health Ministry’s disease control division has activated its operations room to monitor the swine flu situation and informed medical practitioners who are treating cases with symptoms of influenza-like illness or severe pneumonia and persons had visited Mexico, California or Texas, to inform the district health office immediately for preventive and control measures.[89]

Philippines

Philippines' Health Secretary Francisco T. Duque III has ordered the Bureau of Quarantine to use thermal imaging equipment at airports to screen passengers coming from the US for flu symptoms.[90] The Philippines may quarantine travelers arriving from Mexico with fevers.[91] Also, the Secretary of the Department of Agriculture of the Philippines issued an order banning the importation of hogs from the U.S. and Mexico, and the retraction of the restriction of swine influenza vaccine use.[92]

Singapore

Singapore's Minister of Health Khaw Boon Wan has urged citizens to limit travel to affected areas such as Mexico and the United States. The Health Ministry has advised the public to seek immediate medical attention if they experience influenza symptoms within seven days after arriving from affected areas, to maintain good hygiene, and for those who are sick with respiratory illnesses to avoid crowded areas and wear masks.[87]

South Korea

South Korea warned against travel to Mexico City and three Mexican states.[85] The government has also stepped up quarantine and safety checks on travelers arriving from the United States and Mexico, and pork imports from those countries. An emergency quarantine system is also in place, with simple tests conducted on people arriving with flu symptoms at airports.[83]

Thailand

The Thai Government has installed thermal scanners in Suvarnabhumi Airport and two other airports. Airport health officials began using thermal screening equipment to monitor passengers arriving from the southern United States and Mexico for flu-like symptoms including fever to prevent spreading swine flu. Each unit comprises an infrared thermal camera, a processor and a monitor to show the results of readings. Travellers found with suspicious flu symptoms that could develop into swine influenza will be asked to undergo treatment at the staterun Bamras Naradoon Hospital in Nonthaburi. Thai health officials issued a warning against unnecessary travel to Mexico.[93]

Vietnam

Vietnam's Ministry of Health released a emergency dispatch and urged agencies to take precautionary measures against swine flu. In addition, the Preventive Health and Environment Bureau requested all health facilities to carefully monitor any suspected H1N1 case and this Bureau head, Nguyen Huy Nga, also warned the pandemic could enter Vietnam through imported swines or border gates.[94] Thermal imaging devices were dispatched to airports and border gates to screen passengers.[95]

Europe

On April 27, the European Union health commissioner advised Europeans not to travel to the United States or Mexico unless urgent. This followed the first confirmed case being discovered in Spain.[96]

France

Three cases in France are currently under investigation: one in Pau, in Nantes and the last one in Poitiers. Seven other cases have been excluded after analysis.[97]

Germany

Two men and a woman who had been suspected of having the virus tested negative on influenza type A.[98]

Iceland

Iceland is currently being briefed by the WHO and is cooperating closely with ECDC and the EU in terms of monitoring and response. Iceland has not yet implemented travel restrictions but has warned people traveling to Mexico and The United States (especially California and Texas) to exercise caution and to contact a doctor immediately if they start showing symptoms of swine flu.[99]

In a risk assessment made by the Icelandic government in 2008 in case of a influenza pandemic two scenarios are envisioned:

  • A worse case scenario where 50% of the Icelandic population are infected and 3% of the infected population die.
  • A milder scenario where precautionary measures prevent infection, 25% of the Icelandic population are infected and 1% die.

[100]

Italy

Italy's agriculture lobby, Coldiretti, warned against panic reaction, noting that farmers lost hundreds of millions of euros due to consumer boycotts during the 2001 mad cow scare and the 2005 bird flu outbreak.[101]

Netherlands

The Netherlands National Institute for Public Health and the Environment advised any traveller who returned from Mexico since April 17 and developed a fever of 38.5 degrees Celsius (101.3 degrees Fahrenheit) within four days of arriving in the Netherlands to stay at home.[91]

Norway

On April 27, one person in Haugesund, Norway was tested negative for swine flu, after returning from a vacation in Houston, Texas,[102] where there are no suspected cases of swine flu. Two people in their thirties was also tested for flu-like symptoms in Tromsø after vacationing in Mexico [103], but test results were negative [104]

The Norwegian government projects that in the worst case, 1.2 million Norwegians may fall ill and 13,000 may die.[105]

Poland

Three cases in Poland are currently under investigation: one in Zielona Góra and two in Wroclaw.[106] The Polish Foreign Ministry issued a statement recommending that citizens avoid travel to affected areas until the outbreak is totally contained.[91]

Russia

Russia has banned the import of meat products from Mexico, California, Texas and Kansas.[101]

Serbia

Serbia, on Saturday, banned all imports of pork from North America, despite reassurances from the FAO (Food and Agriculture Organization of United Nations) that pigs appear not to be the immediate source of infection.[101]

Spain

  Confirmed cases
  Unconfirmed or suspected cases

On April 27 the Spanish Ministry of Health and Social Policy announced that a man in Castilla-La Mancha who had recently returned from Mexico had contracted the disease. The man, aged 23, had returned from Mexico on April 22 and had been quarantined on the 25th. This was the first confirmed case in Europe.[107]

The Spanish government is also observing other 35 possible swine flu cases in the Basque Country, Catalonia, the Balearic Islands, Andalusia, Murcia, Madrid and the Valencian Community.[108]

AENA, the Spanish state owned company who manages all Spanish airports and Air Traffic Control established a protocol for the flights coming from and to Spain from the affected areas.[109] Three patients who had just returned from Mexico were under observation in multiple regions of Spain.[101]

Sweden

On April 27, at least five Swedish people were tested for swine flu after returning from trips in Mexico and the USA, but the results were negative.[110]

Switzerland

The first suspicious case was officially confirmed on April 27. A young man returning from holiday in Mexico informed his family doctor about fever and flu-like symptoms. He was immediately put under quarantine in a hospital. Four more people are under observation. [111]

United Kingdom

In the United Kingdom, on April 25, 2009, a member of the cabin crew from British Airways flight number BA242 was taken to Northwick Park Hospital in Harrow and quarantined after falling ill with flu-like symptoms on a flight from Mexico City to Heathrow.[112] On April 26 after undergoing testing, Northwick Park Hospital confirmed the crew member did not have the swine flu.[113]

On April 26, two people were admitted to Monklands Hospital in Scotland with mild flu-like symptoms after returning from Mexico. On 27 April 2009, these cases were confirmed as mild swine flu.[114][115] Four people were given medication and advised to stay in their home in Stanwick, Northamptonshire, again after returning from Mexico with flu-like symptoms.[116] In both cases the symptoms were said to be mild. On the same date, passengers were held on planes arriving at Heathrow, from Mexico City, whilst officials carried out health checks.[117]

A Canadian woman visiting Manchester has been submitted to hospital for tests.[118]

10 other cases are being investigated as swine flu in Nottingham.[119]

On 27 April the UK Health Secretary Alan Johnson told the House of Commons that 25 possible cases had been reported. He also stated that protective facemasks were not planned, as despite their use in Mexico, scientific evidence did not suggest that they proved an effective preventative measure. [120]

On the evening of 27 April Scottish Health Minister Nicola Sturgeon reported that seven people who were in contact with the two confirmed Scottish cases are showing flu like symptoms.[121][122]

North America

Outbreak evolution in North America:
  Deaths
  Confirmed cases
  Unconfirmed or suspected cases

Canada

Four cases of swine flu have been confirmed in Nova Scotia and two in British Columbia.[123] Nova Scotia's chief medical officer, Dr. Robert Strang, said on 26 April that the National Microbiology Laboratory in Winnipeg confirmed late the previous day, that four young people in the province were recovering from "relatively mild" cases of the disease. The four all attended King's-Edgehill preparatory school in Windsor; and one of the four infected students had been on a recent school trip to the Yucatán Peninsula.[123][124]

Dr. Michael Gardam, director of infectious disease prevention and control at Ontario's public health agency, 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.[125] In preparing for and dealing with an influenza pandemic, the Public Health Agency of Canada follows the WHO's categories, but has expanded them somewhat.[126] Despite initial reports of two swine influenza cases in a Montreal hospital, an official on the Montreal regional health board confirmed negative results for all quarantined patients at the hospital and that no quarantines were currently in effect at the hospital.[127]

Canada's Chief Public Health Officer, Dr. David Butler-Jones, stated that the six affected Canadians suffered from only mild symptoms and have already started to recover. Butler-Jones warned against complacency though, stating that the fact that only mild cases have been reported so far "doesn’t mean we won’t see either some more severe illness or potentially deaths."[128] In both provinces, the cases either involved people who had recently returned from Mexico or those in close contact with them.[129]

Mexico

Dr. Jose A. Cordova Villalobos, Mexico's Secretary of Health has stated that since March 2009, there have been over 1,995 suspected cases and 149 deaths, with 20 confirmed to be linked to a new swine influenza strain of Influenza A virus subtype H1N1.[130][131] As of April 26 there have been 1,614 cases, with 103 deaths and about 400 patients in hospital. Around two-thirds of the sick patients had recovered.[132]

Mexican soldiers distributing protective masks to citizens

Soldiers mobilized by the Mexican government have handed out six million surgical masks to citizens in and around Mexico City.[133] On April 24, 2009, schools (from pre-school to university level) as well as libraries, museums, concerts and any public gathering place, were shut down by the government in Mexico City and the neighboring State of Mexico to prevent the disease from spreading further; the schools in Mexico City, the State of Mexico, and the state of San Luis Potosí will remain closed through at least 5 May.[134] Marcelo Ebrard, Mexico City's mayor, has also asked all night-life operators to shut down their places for ten days to prevent further infections.[135] José Ángel Córdova, federal Secretary of Health, said on April 24 that schools will probably be suspended for at least the following week then, and that it will take around ten days to see the evolution of the virus' behavior, and to consider other measures after such.[136] On April 25, President Felipe Calderón declared an emergency which granted him the power to suspend public events and order quarantines.[137] Hours later, Córdova announced classes will be officially suspended through May 6.[138] On 26 April, Natividad Gonzalez Paras, governor of the northeastern State of Nuevo León, announced that state-wide schools will remain closed until 6 May, and established a quarantine system in airports, central bus stations and the creation of observation points mainly in the southern part of the state at the nearest highways to the borders with other states, in order to realize tests conducted on people arriving from other states. However, as for April 26, there are no confirmed reported cases of infection in this state.[139]

On 26 April, the World Bank announced US$ 25 million in immediate aid loans to Mexico, an additional US$ 180 million for long-term assistance to address the outbreak, and advice on how other nations have responded to similar crises.[133]

On 27 April, the Secretaría de Educación Pública announced that all schools in Mexico will remain closed at least until May 6th.[140]

United States

Officials in the United States confirmed that seven people in California, two students from a high school in Texas, and a married couple in Kansas were infected with the A/09(H1N1) swine flu; all have recovered.[141] One additional student from the same high school in Texas is suspected of probably having the influenza strain. St. Francis Preparatory School, a private school in New York, has 28 confirmed cases of swine flu.[142] The cases in Kansas and New York are linked to travel to Mexico; most of the cases in California and Texas are not linked and may reflect localized outbreaks of this virus in those areas.[143] One case has been confirmed in Elyria, Ohio.[141] A public health emergency has been declared, but it was said that this is standard procedure in cases as divergent as the recent inauguration and flooding.[144]

Cases in the USA have been less severe than in Mexico, with no deaths and only one of the first 20 confirmed cases hospitalized.[60][145] By April 27, all 20 of those cases had recovered.[146]

The United States of America has declared a state of Public Health Emergency. According to the New York Times, "the emergency declaration frees resources to be used toward diagnosing or preventing additional cases and releases money for more antiviral drugs," including the transfer of approximately 12 million influenza medications from a federal stockpile to states.[133][147] The U.S. plans to follow a guidebook developed over the past five years to fight a pandemic flu, such as H5N1.

Oceania

New Zealand

Following a three-week language trip to Mexico, ten students from Rangitoto College, a secondary school in North Shore City, Auckland, exhibited influenza symptoms. All 22 students and three accompanying teachers from the trip are currently in home isolation, with oseltamivir provided to the patients and those in contact with them. 10 students have tested positive for an influenza A virus;.[148][149] Samples were sent to the Melbourne WHO lab for A/09 (H1N1) testing. A further five people are being tested for influenza A.[150]

CDC conference with the media on the swine flu outbreak on April 25, 2009

South America

Argentina

All passengers arriving to the country from Mexico and United States must fill out a form to be located in case they show symptoms of flu according to an Epidemic Alert order issued by The Ministry of Health.[151]

Brazil

Two people who had arrived in Brazil from Mexico with symptoms of an undefined illness were hospitalized in São Paulo on April 25. It was initially suspected that they were suffering from the swine flu virus.[152] The Brazilian Ministry of Health later issued a press release stating that while the exact cause of the two patients illnesses remained unknown, they "did not meet the definition of suspected cases of swine influenza because they did not have signs and symptoms consistent with the disease: fever over 39°C, accompanied by coughing and/or a headache, muscle and joint [pain]."[153]

The press release also stated that airports would monitor travelers arriving from affected areas, under the direction of the National Sanitary Surveillance Agency (ANVISA). Air crews are also being trained on signs and symptoms of swine influenza so that passengers displaying symptoms may receive guidance from ANVISA upon arrival.

Chile

The Health Ministry reported that three people suspected of being infected with swine flu are under observation in the Coyhaique Regional Hospital, the Carlos Van Buren Hospital in Valparaíso and the Hospital del Tórax in Santiago. The Health minister Alvaro Erazo stated that two of the cases have initially tested negative to exams, indicating they are likely not infected, while a third case is under study. Regarding the Chivas de Guadalajara football team, slated to arrive back in Chile from Mexico, the minister stated they will undergo examination as will other passengers.[154]

Colombia

The Minister of Social Protection, Diego Palacio Betancourt, announced on April 26, 2009 that 12 suspect cases have been detected, 9 in Bogotá and 3 on the Caribbean coast. Samples of the virus have been sent to the USA for comparisons and analysis and confirmation should be expected in a couple of days.[155]

Peru

The Governor of Callao, Alex Kouri, ordered that all passengers from any infected country, mainly Mexico and USA, must be checked before their arrival on Peruvian territory. Also, the Peruvian government must be warned of any case or symptom of fever. This step is in order to prevent any infections, since the main port and airport of Peru are located in Callao. Also, the government has prepared a special area at the Hospital "Daniel Alcides Carrión" to treat cases of this disease.[156]

The first suspicious case has been detected in the morning of April 27, 2009. It was a Peruvian woman who returned from Mexico.[157]

See also

References

  1. ^ http://news.bbc.co.uk/2/hi/americas/8021656.stm
  2. ^ "WHO | Current WHO phase of pandemic alert". Who.int. Retrieved 2009-04-27.
  3. ^ a b "Deadly new flu virus in US and Mexico may go pandemic". New Scientist. 2009-04-24. Retrieved 2009-04-26. Cite error: The named reference "NewSci-20090424-pandemic" was defined multiple times with different content (see the help page).
  4. ^ "CDC Press Briefing Transcripts April 24, 2009". Centers for Disease Control and Prevention. 2009-04-24. Retrieved 2009-04-25.
  5. ^ a b c d Chan, Margaret (2009-04-25). "Statement by WHO Director-General, Dr Margaret Chan: Swine influenza". World Health Organization. Retrieved 2009-04-26.
  6. ^ "Mexico extends school closures in flu outbreak - The Official KFVS12 and Heartland News Web Site |". Kfvs12.com. Retrieved 2009-04-27.
  7. ^ "Schertz-Cibolo-Universal City ISD". Scuc.txed.net. 2009-02-23. Retrieved 2009-04-27.
  8. ^ "St. Francis Preparatory School Online". Sfponline.org. Retrieved 2009-04-27.
  9. ^ "All schools closed in Mexico - The CNN Wire - CNN.com Blogs". Cnnwire.blogs.cnn.com. 2007-12-17. Retrieved 2009-04-27.
  10. ^ "Mexico Orders All Schools Closed - Schools Mexico Flu Closed". WKRG.com. Retrieved 2009-04-27.
  11. ^ "Fact sheet N°211: Influenza". World Health Organization. 2003-03. Retrieved 2009-04-26. {{cite web}}: Check date values in: |date= (help)
  12. ^ "Flu Strikes a Milder Blow This Season". Forbes. 2009-04-07. Retrieved 2009-04-26.
  13. ^ Steven Reinberg (2009-04-08). "Flu Strikes a Milder Blow This Season". HealthDay.
  14. ^ "WHO names three new strains for 2008 flu vaccine". CTV News. 2008-02-15.
  15. ^ "Swine Influenza (Flu)". CDC. 2009-04-25. Retrieved 2009-04-26.
  16. ^ a b "Q&A: Swine flu". BBC News.
  17. ^ McNeil Jr., Donald G. (209-04-26). "Flu Outbreak Raises a Set of Questions". New York Times. Retrieved 2009-04-26. {{cite news}}: Check date values in: |date= (help)
  18. ^ a b Mark Stevenson (2009-04-25). "U.S., Mexico battle deadly flu outbreak". Associated Press.
  19. ^ Brown David (26 April 2009). "U.S. Slow to Learn of Mexico Flu". Washington Post.
  20. ^ Mike Stobbe (April 21, 2009). "Officials alert doctors after 2 California children infected with unusual swine flu". Associated Press. Retrieved April 24, 2009.
  21. ^ David Brown (April 22, 2009). "New Strain of Swine Flu Investigated: Two Children in San Diego Area Had No Contact with Pigs". Washington Post. Retrieved April 24, 2009.
  22. ^ "El virus mutó en mujer de Oaxaca". Retrieved 2009-04-27. {{cite web}}: Text "publisherEl Universal" ignored (help)
  23. ^ "Grippe porcine: Mexico sous tension, le monde en alerte - Yahoo! Actualités". Fr.news.yahoo.com. Retrieved 2009-04-27.
  24. ^ Herald Sun story raising death toll to 103
  25. ^ a b Lacey, Marc (April 24, 2009). "Fighting Deadly Flu, Mexico Shuts Schools". The New York Times. {{cite news}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  26. ^ a b c d "Influenza-Like Illness in the United States and Mexico". World Health Organization. 2009-04-24. Retrieved 2009-04-25.
  27. ^ "World on alert as Mexico flu epidemic fear grows". Reuters. 2009-04-26. Retrieved 2009-04-26.
  28. ^ "Experts probe deadly Mexico flu". BBC News. 2009-04-24. Retrieved 2009-04-25.
  29. ^ David Kirby, Swine Flu Outbreak – Nature Biting Back at Industrial Animal Production?, The Huffington Post, 26 April 2009
  30. ^ http://www.swineflu.org.uk. Retrieved 2009-04-26. {{cite news}}: Missing or empty |title= (help)
  31. ^ Granjas Carroll provocó la epidemia de males respiratorios en Perote, según agente municipal, La Jornada, 5 April 2009. Template:Es icon
  32. ^ Swine-flu outbreak linked to Smithfield factory farms, Grist, 25 April 2009
  33. ^ Smithfield Foods - Smithfield Foods Says It Found No Evidence of Swine Influenza at Its Mexican Joint Ventures, April 26 2009
  34. ^ "Deadly new flu virus in US and Mexico may go pandemic". New Scientist. 2009-04-26. Retrieved 2009-04-26.
  35. ^ Robert Roos (2007-12-20). "New swine flu virus supports 'mixing vessel' theory".
  36. ^ "Identification of H2N3 influenza A viruses from swine in the United States". PNAS. 2007-12-26. doi:10.1073/pnas.0710286104.
  37. ^ Steven Reinberg (2009-04-24). "Swine Flu Cases Now Total 7: CDC". ABC News.
  38. ^ Rob Stein (2009-04-23). "In California and Texas, 5 New Swine Flu Cases". Washington Post.
  39. ^ "CDC Briefing on Public Health Investigation of Human Cases of Swine Influenza". CDC online newsroom. 2009-04-23.
  40. ^ "Influenza-like illness in the United States and Mexico". WHO. 2009-04-24.
  41. ^ "Likely Swine Flu In Auckland New Zealand Students". 2009-04-26.
  42. ^ "GISAID".. GISAID is freely available, but subject to license terms and currently subject to a backlog of applications following the outbreak. Some discussion of sequence homologies can be found at "FluTracker.com".. The first strains released are A/California/09/2009 7M 2009-04-15, A/Texas/05/2009 16M 2009-04-15, A/Texas/04/2009 16M 2009-04-14, A/California/07/2009 54M 2009-04-09, A/California/06/2009 41F 2009-04-16, A/California/05/2009 9F 2009-03-30, and A/California/04/2009 10M 2009-04-01.
  43. ^ Susan Watts (2009-04-25). "Experts concerned about potential flu pandemic". BBC.
  44. ^ Dr. Henry Niman at FluTrackers has described the homologies of the genes as PB2 Avian North America, PB1 Human circa 1993, PA Swine Eurasia and/or North America, HA Swine North America, NP Swine Eurasia and/or North America, NA Swine Eurasia, MP Swine Eurasia, NS Swine Eurasia and/or North America.[1]
  45. ^ "Swine Influenza A (H1N1) Infection in Two Children --- Southern California, March--April 2009". CDC MMWR. 2009-04-22.
  46. ^ "Update: Swine Influenza A (H1N1) Infections --- California and Texas, April 2009". CDC MMWR. 2009-04-24.
  47. ^ Centers for Disease Control and Prevention > Key Facts about Swine Influenza (Swine Flu) Retrieved on April 27, 2009
  48. ^ Murray CJ, Lopez AD, Chin B, Feehan D, Hill KH (2006). "Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis". Lancet. 368 (9554): 2211–8. doi:10.1016/S0140-6736(06)69895-4. PMID 17189032. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  49. ^ "CDC Briefing on Public Health Investigation Reuters of Human Cases of Swine Influenza (transcript)". CDC. 2009-04-24.
  50. ^ "CDC says too late to contain U.S. flu outbreak". Reuters. 2009-04-24.
  51. ^ "Swine flu is worse in Mexico, but why? | World | Chron.com - Houston Chronicle". Chron.com. Retrieved 2009-04-26.
  52. ^ Besser, Richard, Acting Director CDC. CDC Press Transcript April 24, 2009 (unedited): "there are really three things we want to look for when we’re thinking about whether a virus is causing a new pandemic...".
  53. ^ U.S. Centers for Disease Control. Morbidity and Mortality Weekly Report Dispatch, April 21, 2009.
  54. ^ "Questions & Answers: Swine Influenza and You". CDC.gov. 2009-04-27. Retrieved 2009-04-27.
  55. ^ Global spread of H5N1
  56. ^ Fighting Deadly Flu, Mexico Shuts Schools, The New York times, 24 April 2009.
  57. ^ Stein, Rob and Brown, David. Washington Post (April 25, 2009). Swine Flu Found in Mexican Outbreak
  58. ^ Mike Stobbe, "Swine Flu's Course Unpredictable", Express (Washington, D.C.), April 27, 2009, p. 3.
  59. ^ "CDC - Influenza (Flu) | Swine Influenza (Flu) Investigation". Cdc.gov. Retrieved 2009-04-27.
  60. ^ a b c "CDC Press Briefing Transcript - Media Availability on CDC Investigation of Human Cases of Swine Influenza". CDC. 2009-04-25. Retrieved 2009-04-26.
  61. ^ "CDC Swine Flu FAQ". Cdc.gov. Retrieved 2009-04-27.
  62. ^ "Baxter to work to contain Mexico flu outbreak". Chicago Tribune. 2009-04-25. Retrieved April 26, 2009.
  63. ^ "IL-based Baxter working on swine flu vaccine". BusinessWeek. AP. 2009-04-25. Retrieved April 26, 2009.
  64. ^ "WHO Says Initial Findings Show Swine Flu Responds To Tamiflu". Nasdaq.com. Retrieved 2009-04-25.
  65. ^ "Swine influenza questions and answers" (PDF). WHO. Retrieved 2009-04-26.
  66. ^ "Tamiflu product information (prescribing information document)" (PDF). Roche Laboratories, Inc. 2008. Retrieved 2009-04-26. {{cite web}}: Unknown parameter |month= ignored (help)
  67. ^ "Antiviral Drugs and Swine Influenza". CDC.gov. 2009-04-27. Retrieved 2009-04-27.
  68. ^ "Mary Ann Liebert, Inc. - Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science - 7(1):101". Liebertonline.com. doi:10.1089/bsp.2009.0011. Retrieved 2009-04-27. {{cite web}}: Check |doi= value (help)
  69. ^ "Americans told to wear masks as swine flu spreads round globe". Times Online. Retrieved 2009-04-27.
  70. ^ "Avian Flu Q&A". Kaysmedical.com. Retrieved 2009-04-27.
  71. ^ "All About Bird Flu Masks - Emergency Preparedness". Home Defense HQ. Retrieved 2009-04-27.
  72. ^ "Swine flu cases confirmed in UK". BBC News. April 27, 2009. Retrieved 2009-04-27.
  73. ^ a b "WHO ready with antivirals to combat swine flu". Reuters. 2009-04-24.
  74. ^ "Virtual press briefing - swine influenza (April 25, 2009)". WHO.
  75. ^ "Transcript of the Press Conference undertaken with [[Dr Keiji Fukuda]]" (PDF). WHO. {{cite web}}: URL–wikilink conflict (help)
  76. ^ "WHO calls emergency meeting on swine flu".
  77. ^ "WHO | Current WHO phase of pandemic alert". Who.int. Retrieved 2009-04-26.
  78. ^ "Mexico Takes Powers to Isolate Cases of Swine Flu". The New York Times. 2009-04-25. Retrieved 2009-04-26.
  79. ^ "Suspected Mexico flu toll hits 81". BBC. 2009-04-26. Retrieved 2009-04-26.
  80. ^ "Current WHO phase of pandemic alert". WHO. Retrieved 2009-04-26.
  81. ^ "WHO Pandemic Influenza Phases". Who.int. Retrieved 2009-04-27.
  82. ^ Dr Margaret Chan (2009-04-27). "Swine influenza". World Health Organization. Retrieved 2009-04-27.
  83. ^ a b "FACTBOX-Asia moves to ward off new flu virus". Reuters. 2009-02-09. Retrieved 2009-04-26.
  84. ^ "Four 'mild' cases of swine flu confirmed in Nova Scotia". Ottawacitizen.com. Retrieved 2009-04-26.
  85. ^ a b c WHO tries to come up with swine flu plan. Associated Press
  86. ^ "Japan on high alert for swine flu after outbreak in Mexico". Kyodo News. 2009-04-26. Retrieved 2009-04-26.
  87. ^ a b "FACTBOX-Asia moves to ward off new flu virus". Reuters. 2009-04-26.
  88. ^ "Malaysia on alert after deadly flu hits Mexico". TheStar Online. 2009-04-26.
  89. ^ "Operations room activated to monitor swine flu". Malaysian Insider. 2009-04-26.
  90. ^ "Quarantine screening of US passengers ordered | Manila Bulletin". Mb.com.ph. Retrieved 2009-04-26.
  91. ^ a b c Frank Jordans (2009-04-25). "WHO declares international concern over swine flu". Associated Press.
  92. ^ "RP bans pork, hogs from US, Mexico". ABS-CBN. 2009-04-26. Retrieved 2009-04-26.
  93. ^ Nation, The. "Swine flu scanners at 3 key airports". Nationmultimedia.com. Retrieved 2009-04-27.
  94. ^ "Vietnam on alert as new killer flu stalks Mexico, US". Thanh Nien. Retrieved 2009-04-2007. {{cite web}}: Check date values in: |accessdate= (help)
  95. ^ "Thế giới báo động đại dịch cúm heo" (in Vietnamese). Tuoi Tre. Retrieved 2009-04-2007. {{cite web}}: Check date values in: |accessdate= (help)
  96. ^ "Europeans urged to avoid Mexico and US as swine flu death toll exceeds 100". Guardian. 27 April 2009. Retrieved 2009-04-27.
  97. ^ "Grippe porcine: pas de cas avéré en France - Yahoo! Actualités". Fr.news.yahoo.com. Retrieved 2009-04-27.
  98. ^ "Spiegel Online: Bielefeld - Entwarnung bei Schweinegrippe-Verdachtsfällen". Spiegel Online. 2009-04-27. Retrieved 2009-04-27.
  99. ^ "Landlæknisembættið - Fréttir". Landlaeknir.is. Retrieved 2009-04-27.
  100. ^ http://www.influensa.is/lisalib/getfile.aspx?itemid=3515
  101. ^ a b c d Jordans Frank (26 April 2009). "Swine flu fears prompt quarantine plans, pork bans". The Associated Press. Retrieved 2009-04-26.
  102. ^ Person testes for svineinfluensa
  103. ^ "To testes for svineinfluensa i Tromsø - Nyheter - Innenriks". Aftenposten.no. Retrieved 2009-04-27.
  104. ^ "Avblåser svineinfluensa i Tromsø". Dagbladet.no. Retrieved 2009-04-28. {{cite web}}: Check |url= value (help)
  105. ^ "13.000 døde av svineinfluensa - VG Nett om Svineinfluensa". Vg.no. Retrieved 2009-04-27.
  106. ^ "RMF: Przyjechała z Meksyku. Od kilku tygodni źle się czuje". gazeta.pl. Retrieved 2009-04-27.
  107. ^ "Europe's first swine flu case confirmed in Spain". Agence France-Presse. 27 April 2009. Retrieved 2009-04-27.
  108. ^ "Sanidad confirma un caso de gripe porcina en Albacete". eitb.com. Retrieved 2009-04-27.
  109. ^ "Sanitary protocol to follow, recommended by AENA" (PDF) (in Spanish). aena.es. Retrieved 2009-04-26.
  110. ^ TT. "Ingen konstaterad smitta i Sverige | Inrikes | SvD" (in Template:Sv icon). Svd.se. Retrieved 2009-04-27.{{cite web}}: CS1 maint: unrecognized language (link)
  111. ^ [2]
  112. ^ "Cabin crew member in hospital after flight from swine flu-struck Mexico". Guardian. Retrieved 2009-04-27.
  113. ^ "UK monitoring swine flu outbreak". BBC. 2009-04-26. Retrieved 2009-04-26.
  114. ^ "Scotland | Glasgow, Lanarkshire and West | Scots swine flu cases confirmed". BBC News. Retrieved 2009-04-27.
  115. ^ "Scots tourists in swine flu alert". BBC. 2009-04-26. Retrieved 2009-04-26.
  116. ^ "England | Northamptonshire | Family alert to swine flu illness". BBC News. 2009-04-26.
  117. ^ "Swine flu: passengers flying in to Heathrow from Mexico inspected on runway". The Daily Telegraph. 2009-04-26. Retrieved 2009-04-26.
  118. ^ "Swine Flu: Canadian Suspect In UKTests On Couple In Scottish Hospital Contingencies Travel | UK News | Sky News". News.sky.com. Retrieved 2009-04-27.
  119. ^ "Ten people tested for swine flu in East Midlands". Thisisnottingham.co.uk. 2009-04-22. Retrieved 2009-04-27.
  120. ^ "UK probes '17 swine flu reports'".
  121. ^ Daniel Martin (27 April, 2009). "Swine Flu: Now The Battle To Contain It". Daily Mail. Miss Sturgeon said that they had not gone to a doctor until Saturday, four days after returning from Mexico where the virus is believed to have first crossed from pigs to people. Of the 22 people who had been in contact with them, seven were showing mild symptoms. She said doctors had been able to give anti-virals 'much more quickly' to contacts of the seven, improving the chances of stopping the virus spreading. {{cite news}}: Check date values in: |date= (help)
  122. ^ "Swine flu in Britain: Two Scottish holidaymakers test positive for deadly virus | Mail Online". Dailymail.co.uk. Retrieved 2009-04-27.
  123. ^ a b "4 cases of swine flu confirmed in Nova Scotia, 2 in B.C." Canadian Broadcasting Corporation. 2009-04-26.
  124. ^ "Flu Update, Sunday, April 26, 2009" (Press release). King's-Edgehill School. April 26, 2009. Retrieved April 26, 2009.
  125. ^ "Swine flu not as serious as SARS: Canada's Ontario". Reuters.
  126. ^ "Public Health Agency of Canada: The Canadian Pandemic Influenza Plan for the Health Sector". Phac-aspc.gc.ca. 2009-01-06. Retrieved 2009-04-27.
  127. ^ "Swine-flu fears at Lakeshore General unfounded". The Gazette (Montreal). 2009-04-25. Retrieved 2009-04-25.
  128. ^ "News & Features - Swine flu confirmed in Canada, Unlike deadly outbreak in Mexico, the cases in Nova Scotia and B.C. were mild and didn't require hospitalization". HealthZone.ca. Retrieved 2009-04-27.
  129. ^ "Six swine flu cases confirmed in Canada". CTV News. April 26, 2009.
  130. ^ "Mexico closes schools nationwide due to swine flu". Associated Press.
  131. ^ "Influenza-Like Illness in the United States and Mexico". World Health Organization.
  132. ^ "Reuters AlertNet - Swine flu death toll in Mexico rises to 103". Alertnet.org. Retrieved 2009-04-27.
  133. ^ a b c Neergaard, Lauran (2009-04-26). "World govts race to contain swine flu outbreak". Associated Press. Retrieved 2009-04-26.
  134. ^ "AP Top News at 9:11 p.m. EDT". Associated Press. 2009-04-25. Retrieved 2009-04-25.
  135. ^ [Pide Ebrard parar 10 días vida nocturna "Estima SSA 10 dias de alerta por influenza"]. Reforma. 2009-04-25. {{cite web}}: Check |url= value (help)
  136. ^ "Estima SSA 10 dias de alerta por influenza". El Universal. 2009-04-25.
  137. ^ "Mexico's Calderon Declares Emergency Amid Swine Flu Outbreak". Bloomberg. 2009-04-25.
  138. ^ "Se suspenden clases hasta el 6 de mayo" (in Spanish). Excélsior. 2009-04-25.
  139. ^ "Nuevo Leon schools to be closed down until 6 May" (in Spanish). El Universal. 2009-04-26.
  140. ^ "All schools closed in Mexico". CNN. 2009-04-27.
  141. ^ a b "Human Swine Influenza Investigation". US Centers for Disease Control (CDC).
  142. ^ "Mayor Says City Confirms 20 More Cases Of Swine Flu". New York 1. April 27, 2009.
  143. ^ Thomas H. Maugh II (April 24, 2009). "Eight swine flu cases identified in U.S.: All victims, six of them in California, have recovered. Officials say the new virus is easily passed, but does not appear to be especially virulent. Researchers plan to go to Mexico, where the viruses in 12 cases match six in the U.S.". Los Angeles Times. {{cite news}}: |access-date= requires |url= (help)
  144. ^ "US Declares Public Health Emergency for Swine Flu". Associated Press.
  145. ^ CDC Emergency (2009-04-27). "Only 1 of the 20..." Twitter. Retrieved 2009-04-27.
  146. ^ CDC Emergency (2009-04-27). "20 confirmed cases..." Twitter. Retrieved 2009-04-27.
  147. ^ Healy Jack, Stolberg, Sheryl Gay (26 April 2009). "U.S. declares public health emergency over swine flu". New York Times.{{cite news}}: CS1 maint: multiple names: authors list (link)
  148. ^ "Students likely to have swine flu". TV3 (3 News). 2009-04-06. Retrieved 2009-04-26.
  149. ^ "NZ students in swine flu scare". The New Zealand Herald. April 26, 2009.
  150. ^ "NZ authorities prepare for worst as swine flu toll rises". The New Zealand Herald. 2009-04-27. Retrieved 2009-04-27.
  151. ^ http:www.clarin.com/diario/2009/04/26/elmundo/i-01906060.htm
  152. ^ "Hospital em SP examina suspeita de gripe suína no País". Agencia Estado. 2009-04-26. Retrieved 2009-04-27.
  153. ^ "Ocorrências de casos humanos de influenza suína no México e nos EUA" (Press release) (in Portuguese). Brazilian Ministry of Health. 2009-04-26. Retrieved 2009-04-27.
  154. ^ "Ministerio de Salud detectó tres casos sospechosos de gripe porcina en Chile". Cooperativa.cl. 2009-04-25. Retrieved 2009-04-25. {{cite web}}: |first= missing |last= (help)
  155. ^ Cite error: The named reference elespectador-12 was invoked but never defined (see the help page).
  156. ^ "Perú toma precauciones con la gripe porcina". Retrieved 2009-04-25.
  157. ^ "Viajero procedente de México tiene aparentes síntomas de gripe porcina | El Comercio Perú". Elcomercio.com.pe. Retrieved 2009-04-27.

USA Centers for Disease Control (CDC)

European Centre for Disease Prevention and Control (ECDC)