2009 H1N1 Infuenza -- Just the

Facts: Clinical Features and

Epidemiolo!
John G. Bartlett, MD Posted: 09/25/2009; Updated: 11/23/2009
Editor's Note: This article will be updated frequently, so check back often
for new information. On October 1, updates were made to weekly !"
in#uen$a data %includin& colle&e data' and reports of bacterial coinfections.
(n#uen$a hospitali$ation data were added as well. On October )*, updates
were made about the declaration of a national emer&ency, weekly !" and
international +1N1 acti,ity, deaths in children and pre&nant women, and
treatment outcomes. !pdates made on No,ember include information on
the true pre,alence of +1N1, pediatric deaths, and underlyin& conditions
in children hospitali$ed with +1N1 in#uen$a. !pdates made on No,ember
1- include new information on the &lobal +1N1 pandemic, the +1N1
situation on colle&e campuses, the e.ect of sick/call policies on the spread
of in#uen$a, and characteristics of patients hospitali$ed with +1N1 infection.
On No,ember )0, updates were made about emer&ency use authority for pandemic
supplies, &uidance for homeless shelters, a summary of the article 1One
2iller 3irus, Three 2ey 4uestions,1 studies on reduced deaths in patients
recei,in& statins, and the role of cytokines in mediatin& the symptoms of
in#uen$a. 5or the latest information on )667 +1N1 in#uen$a, please &o to
the +1N1 8lert 9enter.

Novel Influenza A (H1N1) Timeline
Fe"ruar!
2#$ 2009
Patient ero is said to !e a "#$onth#old %irl &ro$ northern Me'i(o, a((ordin% to
)elia *lp+(he o& the ,nstit+te o& -pide$iolo%i(al Dia%nosis and .e&eren(e in
Me'i(o )it/. 0Cohen J. Swine fu outbreak, day by day. ScienceInsider.
July 17, 2009. Aailable at!
htt"!##blo$s.science%a$.or$#scienceinsider#s"ecial#swine&fu&ti%eline.ht%l
Accessed Se"te%ber 1', 2009.1
%arch &$
2009
,nitial re(o%nition o& (ase in Me'i(o )it/ 2ith $+ltiple (ases reported on
Mar(h 13.
'pril ($ 4+t!rea5 in 6a Gloria, Me'i(o, 2ith atta(5 rate o& "07.
2009
'pril 1)$
2009
8irst 9irolo%i(all/ de:ned (ases and :rst re(o%nied U; (ase: 10#/ear#old !o/
in )ali&ornia 2ith positi9e test &or in<+ena =1 anti%en !+t ne%ati9e &or seasonal =1 and =3.
'pril 2($
2009
United ;tates de(lares p+!li( health e$er%en(/.
'pril 29$
2009
Me'i(an Ministr/ o& =ealth reports 1#$onth total o& 2155 patients 2ith se9ere
pne+$onia and 100 deaths.
%a! 9$
2009
Glo!al epide$i( re(o%nied 2ith (aseloads that $at(hed international air#tra>(
patterns &ro$ Me'i(o )it/. 0(han (, Arino J, )u *, +a"oso ,, et al. S"read o- a
noel infuen.a A /)1011 irus ia $lobal airline trans"ortation. ? -n%l J Med.
200923'1!212&214. Aailable at! htt"!##content.ne5%.or$#c$i#content#-ull#3'1#2#212 Accessed Se"te%ber 1', 2009
June 11$
2009
Dr. Mar%aret )han, Dire(tor General o& the @orld =ealth 4r%aniation 0@=41,
de(lares phase " pande$i( and (alls 2009 =1?1 A+nstoppa!leA; also notes
that $ost patients in the 2orld 2ith 2009 =1?1 are /o+n%er than 25 /ears o&
a%e and that one third o& serio+s (ases are in pre9io+sl/ health/ /o+n% people.
Jul! 1$
2009
U; (ases appear in all states; esti$ated total is $ore than 1 $illion in&e(ted;
3B7 o& deaths in persons 5#59 /ears o& a%e.
Jul! 1*$
2009
@=4 reports 9C,512 9irolo%i(all/ (on:r$ed (ases and C29 deaths, !+t (onsiders
this the Atip o& the i(e!er%.A * de(ision is $ade to stop (o+ntin% (ases.0*orld )ealth 6r$ani.ation. Chan 7. *orld now at the start o- 2009 infuen.a "ande%ic. June 11,
2009. Aailable at! htt"!##www.who.int#%ediacentre#news#state%ents#2009#
h1n18"ande%ic8"hase'820090'11#en#inde9.ht%l Accessed Se"te%ber 1', 2009
Jul! 20$
2009
)hile reports 2009 =1?1 in t+r5e/s, in(reasin% so+r(es o& the 9ir+s and
introd+(in% the possi!ilit/ o& $i'in% 2ith a9ian %enes.
'uust
2)$ 2009
PresidentDs )o+n(il o& *d9isors anti(ipates that 2009 =1?1 $a/ in&e(t hal& o& the
U; pop+lation, reE+ire 1.3 $illion hospitaliations, and res+lt in 30,000#90,000
deaths. 0,resident:s Council o- Adisors on Science and ;echnolo$y. <.S.
,re"arations -or 2009&)101 Infuen.a. Au$ust 7, 2009. Aailable at!
htt"!##www.whitehouse.$o#assets#docu%ents#,CAS;8)1018+e"ort."d- Accessed Se"te%ber 1', 2009
'uust
&1$ 2009
@=4 predi(ts that 2ithin 2 /ears nearl/ one third o& the 2orld pop+lation 2ill ha9e
!een in&e(ted. 0Chan 7. Swine fu s"readin$ at :unbelieable: rate! *)6 chie-.
(halee5 ;i%es. Au$ust 29, 2009. Aailable at!
htt"!##www.khalee5ti%es.co%#dis"layarticle.as"=9>le?data#international#2009#Au$ust#international8Au$ust2077.9%l@
section?international@col? Accessed Se"te%ber 2A, 2009.1 ;easonal <+ is
+s+all/ a(E+ired !/ 57#207 per season 2ith 200,000 are hospitalied and
an a9era%e o& 3",000 die. /CBC. (ey -acts about seasonal infuen.a /fu1.
Aailable at! www.cdc.$o#fu#key-acts.ht% Accessed Se"te%ber 2A, 2009.1
+cto"er
2#$ 2009
President 4!a$a de(lares =1?1 in<+ena a state o& national e$er%en(/.
Fhis de(laration 2ai9es (ertain re%+lator/ reE+ire$ents &or health(are &a(ilities
in response to e$er%en(ies. /CluDiew. ,resident 6ba%a si$ns e%er$ency
declaration -or )101 fu. 6ctober 24, 2009. Aailable at!
htt"!##www.fu.$o#"ro-essional#-ederal#h1n1e%er$ency10242009.ht%l
Accessed 6ctober 2', 2009.1
Emergency Use Authority and 2! H1N1 Influenza
/Sher%an SE, Coster J, Daid S. E%er$ency use authority and 2009
)101 infuen.a. Fiosecurity Fioterroris% 200927!24A&2A0.1
P+rpose: Fo pers+ade the 8D* to allo2 prod+(ts to !e introd+(ed to
interstate (o$$er(e 2itho+t the +s+al re%+lator/ reE+ire$ents
&or appro9al, (learan(e or li(ensin%. Fhis e$er%en(/ +se
a+thoriation 0-U*1 is G+sti:ed !/ a rele9ant e$er%en(/ and
lasts d+rin% the e$er%en(/.
Pro(ess: ;tep 1 ## Deter$ination o& an e$er%en(/ !/ ;e(retar/ o&
==;, Depart$ent o& =o$eland ;e(+rit/, or Depart$ent o&
De&ense; ;tep 2 ## De(laration o& e$er%en(/ !/ ;e(retar/ o&
==;; ;tep 3 ## ,ss+an(e o& -U*; ;tep C ## Fhe 8D* )o$$issioner
then e'er(ises this a+thorit/ a&ter (ons+ltin% 2ith dire(tors o&
the ?,= and )D).
.eE+estin% an -U*: *n/ entit/ $a/ reE+est e$er%en(/ +se o& a
prod+(t +nder the -U* !/ a pre#-U* s+!$ission to the 8D*. Fhis
$a/ appl/ to prod+(ts that are not 8D* appro9ed, (leared, or
li(ensed, or this $a/ appl/ to ne2 +se o& an appro9ed prod+(t.
-U*s &or 2009 =1?1: 4n *pril 2", 2009, the ==; ;e(retar/
deter$ined that this in<+ena 2as a p+!li( health e$er%en(/
and there ha9e s+!seE+entl/ !een 3 -*Us &or dia%nosti(s,
anti9irals, and $as5s, as s+$$aried !elo2 0Fa!le 11.
,a"le 1- E'.s /elated to H1N1
0roduct 0urpose
1ianostics
r.t#P).
)D) r.F#P). 8l+ Panel
8o(+s Dia%nosti(s
Per$itted )D) to distri!+te test
)leared test &or additional spe(i$ens
Per$itted this test !/ E+ali:ed la!s
'nti2irals
4selta$i9ir
Hana$i9ir
*+thories +se in (hildren
I 1 /r and dosin% (han%es in (hildren J 1 /r
*llo2s +se 2ith 5 s/$pto$s J C3 hrs
*llo2s +se 2ith s/$pto$s J C3 hrs
%as3s
Disposa!le ?95
respirators
*llo2s +se o& 15 t/pes o& ?95 respirators &ro$ the
?ational ;to(5pile !/ %eneral p+!li(
)on(l+sion: Fhe -U* per$its +se o& ne2 prod+(ts ne(essar/ to
respond e>(ientl/ to an e$er%en(/. Pande$i( in<+ena is a
%ood ill+stration o& appropriate +se.
E"idemiology and Im"act
*((ordin% to Dr. Fo$ 8rieden, Dire(tor o& the )D), there is
2idespread =1?1 a(ti9it/ in C" states. =1?1 in<+ena (ontin+es to
!e a disease pri$aril/ in9ol9in% (hildren and /o+n% ad+lts. AMan/
$illionsA o& (ases and $ore than 1000 deaths ha9e o((+rred. Fhis
in<+ena is e'pe(ted to (o$e in 2a9es, and 2e are no2 in the
se(ond 2a9e. Fhis 2a9e $a/ (ontin+e thro+%h the seasonal <+
season 02hi(h pea5s in De(e$!er#8e!r+ar/1 or there $a/ !e a third
2a9e at that ti$e. ?o in(rease in se9erit/ has !een seen, resistan(e
to anti9iral a%ents is rare, and %eneti( $+tations are $ini$al. /CBC
6nline 0ewsroo%. *eekly 2009 )101 Clu 7edia Frie>n$. 6ctober
22, 2009. Aailable at!
htt"!##www.cdc.$o#%edia#transcri"ts#2009#t091023.ht% Accessed
6ctober 2', 2009.1
U"dated Influenza #ata for United $tates% &ased on '#'
$urveillance #ata
8or the 2ee5 endin% ?o9e$!er B, 2009 0in<+ena season 2ee5 CC1:
,n<+ena a(ti9it/ in the United ;tates de(reased sli%htl/.
23C9 in<+ena strains 2ere s+!t/ped: 2330 099.C71 2ere * 2009
0=1?11 and 19 00."1 2ere in<+ena B. *nal/sis o& 319 strains o&
2009 in<+ena * 0=1?11 strains sho2ed relatedness to the
re&eren(e strain +sed in the 2009 * 0=1?11 9a((ine &or all !+t 1
099.B71.
;ensiti9it/ testin% o& 2009 * 0=1?11 strains (olle(ted sin(e
;epte$!er 1, 2009 sho2ed that 3/10B" 2ere resistant to
oselta$i9ir, 0/315 2ere resistant to ana$i9ir, and 152/152
2ere resistant to a$antadines.
Pediatri( deaths attri!+ted to in<+ena sin(e *pril 2", 2009 total
1B9, in(l+din% 1 (ase attri!+ted to seasonal in<+ena, 15" to
2009 * 0=1?11, and 22 to in<+ena *#s+!t/pe +n5no2n.
/CBC, Infuen.a Biision. CluDiew. Aailable at!
htt"!##www.cdc.$o#fu#weekly# Accessed 0oe%ber 13, 20091
U"date( Influenza Activity ) United $tates% &ased on **+,
,e"orts
/CBC. <"date! Infuen.a Actiity G <nited States, Au$. 30&6ct. 31,
2009. 77*+ 7orb 7ortal *kly +e". 20092AH!123'&1241.1
4iral sur2eillance 'uust &0-+cto"er &1$ 2009- @=4 and the
U; ?ational .espirator/ and -nteri( Kir+s ;+r9eillan(e ;/ste$ la!s
tested 1"3,123 respirator/ spe(i$ens:
?+$!er positi9e: C3,535 03071
,n<+ena *: C3,C33 099.371
2009 0=1?11: 32,31C 099.371
;easonal =1: 13 00.171
;easonal B: 35 00.171
'nti2iral resistance- Fhe total n+$!er o& 2009 * 0=1?11 isolates in
the United ;tates 2ith oselta$i9ir resistan(e is 1C 0or a!o+t 0.C71.
4& these, 12 2ere &ro$ patients 2ith pre9io+s e'pos+re to
oselta$i9ir. 4ne had no oselta$i9ir e'pos+re and another is still
!ein% in9esti%ated.
Infuenza-associated hospitalizations- )+$+lati9e in<+ena
hospitaliation rates 2ere s+!stantiall/ ele9ated &or this ti$e o& /ear
0Fa!le 21.
,a"le 2- Infuenza-'ssociated Hospitalizations
'e
/ate510$00
0 pop
0#C
/rs
B.3
5#1B
/rs
2.9
13#C9
/rs
1.2
50#"C
/rs
1.2
J "5
/rs
1.1
0neumonia and infuenza related mortalit!- Pne+$onia or
in<+ena 2as the reported (a+se o& B.C7 o& all deaths &or the 2ee5
endin% 4(to!er 31, 2009, 2hi(h is a!o9e the epide$i( threshold o&
".B7 &or the :&th (onse(+ti9e 2ee5.
0ediatric mortalit!- -i%ht/#:9e deaths ha9e !een attri!+ted to
in<+ena d+rin% this period, in(l+din% 12 in (hildren /o+n%er than 2
/ears, 9 in those a%e 2#C /ears, 30 in those a%e 5#11, and 3C in those
a%e 12#1B /ears. 4& the 35, B3 09271 had $edi(al histories reported,
sho2in% that 5" 0B271 had ris5s &or in<+ena (o$pli(ations. ?ote
that the n+$!er o& pediatri( deaths attri!+ted to in<+ena d+rin% the
past 5 in<+ena seasons has ran%ed &ro$ C" to 153, 2ith an a9era%e
o& 32//ear. Fhe U; data &or *pril 2"#4(to!er 31 sho2s 1C5 pediatri(
deaths, in(l+din% 129 03971 attri!+ted to 2009 * 0=1?11 and 1"
01171 attri!+ted to seasonal in<+ena.
'nti2iral usae- .ates o& anti9iral +sa%e in hospitals is
disappointin%. .e(ent reports indi(ate that 217#257 o& hospitalied
patients 2ith la!orator/#(on:r$ed 2009 * 0=1?11 in<+ena ha9e not
re(ei9ed anti9irals, and those 2ho did o&ten had a 1# to 2#da/
postad$ission dela/ in re(ei9in% anti9irals. /Iouie J(, Acosta 7,
*inter (, et al. Cactors associated with death or hos"itali.ation due
to "ande%ic 2009 infuen.a A /)1011in-ection in Cali-ornia. JA7A.
20092302!1H9'&19022 Jain S, (a%i%oto I, Fra%ley A7, et al.
)os"itali.ed "atients with 2009 )101 infuen.a in the <nited States,
A"ril&June, 2009. 0 En$l J 7ed. 200923'1!93A&944.1
6/F77 report- Fhe Beha9ioral .is5 8a(tor ;+r9eillan(e ;/ste$,
esta!lished in 193C at the )D), is the lar%est telephone health
s+r9e/ in the 2orld, 2ith inter9ie2s o& $ore than C00,000 ad+lts
/earl/. Data (olle(ted &ro$ 4(to!er 1 to 4(to!er 11, 2009 indi(ated
that B7 o& the U; ad+lt pop+lation and 207 o& (hildren reported an
in<+ena#li5e illness, altho+%h this s/ste$ (annot distin%+ish a$on%
9iral (a+ses 2hi(h $a/ in(l+de respirator/ s/n(/tial 9ir+s, rhino9ir+s,
and adeno9ir+s, as 2ell as in<+ena. /CBC. Fehaioral +isk Cactor
Sureillance Syste%. Aailable at! htt"!##www.cdc.$o#F+CSS#
Accessed 6ctober 27, 2009.1
International $ituation U"date
LeiGi 8+5+da, MD, MP=, ;pe(ial *d9isor on Pande$i( ,n<+ena to the
@=4 Dire(tor#General, reported on ?o9e$!er 5:
20 (o+ntries ha9e started 2009 =1?1 9a((ination pro%ra$s. ;ide
eMe(ts o& =1?1 9a((ination A$a/ a(t+all/ !e lo2er than 2hat is
seen 2ith seasonal <+ shots.A
Fhe =1?1 9ir+s sho2s $ini$al $+tations to date, !+t this is
e'pe(ted to (han%e as the epide$i( pro%resses.
?or2a/Ds de(ision to $a5e anti#in<+ena dr+%s a9aila!le o9er#the#
(o+nter 2as (onsidered Ainno9ati9e and pr+dentA to relie9e the
o9er!+rdened health s/ste$.
Pande$i( =1?1 in<+ena is the do$inant in<+ena strain in the
2orld and (o$prises 997 o& ?orth *$eri(an strains. ,n areas
2here seasonal <+ has o((+rred, s+(h as -ast *sia, it is
predo$inantl/ in<+ena * 0=3?21. Pande$i( =1?1 is A(ro2din%
o+tA seasonal in<+ena * 0=1?11. Fhis 9iral repla(e$ent has
!een seen in pre9io+s epide$i(s. 0@=4. ?o9e$!er 5, 2009
press (on&eren(e. *9aila!le at:
http://222.2ho.int/$edia(entre/$+lti$edia/s2ine<+press!rie:n
%s/en/inde'.ht$l *((essed ?o9e$!er 10, 2009.1
@=4 reports 3B5,000 (on:r$ed (ases o& =1?1 in<+ena in&e(tion
and C500 deaths. Fhe n+$!er (on:r$ed is a s$all &ra(tion o& the
total. Fhe 9ir+s spread thro+%ho+t the 2orld in " 2ee5s and Ais no2
e9er/2here.A /*)6, ,ande%ic )101 2009 && u"date '9. 6ctober 4,
2009. Aailable at!
htt"!##www.who.int#csr#don#2009810809#en#inde9.ht%l Accessed
6ctober 22, 2009.1
4n 4(to!er 23, @=4 reported 9iral s+!t/pe deter$inations o& 1B,225
isolates &ro$ B59 U; la!s &or 2hi(h s+!t/pin% res+lts 2ere a9aila!le.
Fhe distri!+tion 2as:
2009 in<+ena * 0=1?11: 1B,103 (ases 099.571;
,n<+ena * 0=1?11: 15 (ases;
,n<+ena * =3?2: 3C (ases; and
,n<+ena B: "3 (ases.
/CBC. 2009&2010 infuen.a season week 41 endin$ 6ctober 17,
2009. CluDiew. 6ct 23, 2009. Aailable at!
htt"!##www.cdc.$o#fu#weekly# Accessed 6ctober 2', 2009.1
,he Har2ard i0hone- =ar9ard Medi(al ;(hool no2 oMers an
in<+ena iPhone appli(ation &or N1.99. 8eat+res in(l+de !asi(
in&or$ation a!o+t 2009 =1?1 in<+ena, s+(h as a Ahealth $apA that
indi(ates the state o& the epide$i( in /o+r lo(ation and other
lo(ations. Fhere is also: 011 an intera(ti9e se(tion that helps
indi9id+als to re(o%nie 2009 =1?1 <+; 021 ad9i(e re%ardin% 2hen to
(onta(t a ph/si(ian; 031 hotlines; 0C1 9ideos; and 051 e$er%en(/
n+$!ers. /+ao I. )arard 7edical School launches swine fu i,hone
a"". *ashin$ton ,ost. 6ctober 2', 2009.1
Collees- Fhe *$eri(an )olle%e =ealth *sso(iation 0*)=*1 reports
that &or the 2ee5 endin% 4(to!er 30, 2BC (olle%es and +ni9ersities
ha9e had 9123 ne2 (ases o& ,6,. Fhis represents a 27 in(rease o9er
the pre9io+s 2ee5 and in(l+des 25 hospitaliations and no deaths.
Fhe total &or this a(ade$i( /ear &or 3 $illion st+dents is J "5,000
(ases o& ,6, and 123 hospitaliations. 0AC)A. ,ande%ic infuen.a
sureillance. infuen.a&like illness in colle$es and uniersities.
*eekly Case Bata -or the "eriod 6ctober 17&23, 2009. Aailable at!
htt"!##www.acha.or$#III8sureillance.c-% Accessed 0oe%ber 10,
2009.1
7ic3 lea2e- *!o+t 397 o& pri9ate se(tor 2or5ers do not re(ei9e paid
si(5 da/s a((ordin% to the B+rea+ o& 6a!or ;tatisti(s. Fhe )D) has
en(o+ra%ed e$plo/ers Ato de9elop nonp+niti9e lea9e poli(ies.A @hen
e$plo/ees at @al$art, &or e'a$ple, (all in si(5 the/ re(ei9e Ano pa/A
&or the :rst si(5 da/ 0!+t @al$art does allo2 it to !e ta5en as a
9a(ation or personal lea9e da/1. @hen 2or5ers $iss 1 or $ore da/s
the/ %et a de$erit point; C points o9er " $onths (an res+lt in
2arnin%s &or possi!le dis$issal. * s+r9e/ !/ the ?ational 4pinion
.esear(h )enter at the Uni9ersit/ o& )hi(a%o &o+nd that "37 o& those
not eli%i!le &or paid si(5 da/s said that the/ had %one to 2or5 2ith a
(onta%io+s illness (o$pared 2ith 537 2ho 2ere eli%i!le &or paid si(5
ti$e. Fhe s+r9e/ also &o+nd that 117 said that the/ lost their Go! as
a res+lt o& ti$e ta5en oM &or the$sel9es or a si(5 &a$il/ $e$!er,
and 137 said that the/ 2ere 2arned a!o+t the possi!ilit/ o& losin%
their Go!s. 0Jreenhouse S. Iack o- "aid sick days %ay worsen fu
"ande%ic. 0ew Kork ;i%es. 0oe%ber 2, 2009. Aailable at!
htt"!##www.nyti%es.co%#2009#11#03#business#03sick.ht%l=8r?1
Accessed 0oe%ber 10, 2009.1
6usinesses- * national s+r9e/ o& 105B rando$l/ sele(ted
!+sinesses in " (ate%ories 0s$all, $edi+$, lar%e; (riti(al or
non(riti(al1 2as (ond+(ted !/ the Depart$ent o& =o$eland ;e(+rit/
and the =ar9ard ;(hool o& P+!li( =ealth Fhe st+d/ 2as &+nded !/ the
)D) and too5 pla(e !et2een J+l/ 1" and *+%+st 12, 2009. Le/
:ndin%s &ro$ the s+r9e/ o& !+sinesses 0)arard 6"inion +esearch
,ro$ra%, )arard School o- ,ublic )ealth. Fusiness ,re"aredness!
0oel Infuen.a A /)1011. July 1'&Au$ust 12, 2009. Aailable at!
htt"!##www.hs"h.harard.edu#news#"ress&releases#2009&
releases#businesses&"roble%s&%aintainin$&o"erations&si$ni>cant&
h1n1&fu&outbreak.ht%l Accessed Se"te%ber 1', 2009.1:
BC7 pro9ide paid si(5 lea9e; 3C7 oMer lea9e to (are &or others;
217 pro9ide si(5 lea9e to (are &or (hildren;
"B7 2o+ld note operational pro!le$s i& 507 o& 2or5&or(e 2as oM
$ore than 2 2ee5s;
Paid si(5 lea9e is oMered !/ BC7 and 357 allo2 paid si(5 lea9e to
(are &or &a$il/ $e$!ers;
* do(torDs note is reE+ired &or si(5 lea9e !/ C37, and "97 that
oMer si(5 lea9e reE+ire a do(torDs note to ret+rn a&ter a
(onta%io+s illness 0rele9an(e is (on(ern a!o+t ph/si(ian a((ess
in a pande$i(1;
;trate%ies to de(rease person#person (onta(t 0li5e sta%%ered shi&ts1
(o+ld !e i$ple$ented !/ 507 &or 1#2 2ee5s.
)li(5 here &or in&or$ation a!o+t !+siness plannin% &or in<+ena.
Nursin homes- ?o o+t!rea5s o& the 2009 =1?1 9ir+s ha9e !een
reported to the )D). Fhis is attri!+ted to the ad9an(ed a%es o& $ost
persons in (hroni( (are &a(ilities, 2hi(h is a red+(ed ris5 &or this
9ir+s.
Hospitals- Man/ anti(ipate a s+r%e o& =1?1 in<+ena (ases in the
(o$in% in<+ena season !ased on the e'perien(e in the ;o+thern
he$isphere. Fhe PresidentDs *d9isors esti$ate that there 2ill !e a
307#507 atta(5 rate this 2inter 2ith 1.3 $illion hospitaliations,
2hi(h 2ill pose e'tre$e (hallen%es &or hospitals. * 200" ,nstit+te o&
Medi(ine report indi(ated that e$er%en(/ $edi(ine nation2ide 2as
Aat the !rea5in% pointA in !oth :nan(es and (apa(it/. 0Co%%ittee on
the Cuture o- E%er$ency Care in the <nited States )ealth Syste%,
Institute o- 7edicine. E%er$ency 7edical Serices! At the
Crossroads. *ashin$ton, BC! 0ational Acade%ies ,ress2 2007.1
*n anal/sis !/ the )enter &or Biose(+rit/ at the Uni9ersit/ o&
Pitts!+r%h Medi(al )enter esti$ated that a se9ere pande$i( 2o+ld
reE+ire C."#&old $ore ,)U !eds and 2#&old $ore hospital !eds.
0Fartlett JJ, Forio I. )ealthcare e"ide%iolo$y! the current status o-
"lannin$ -or "ande%ic infuen.a and i%"lications -or health care
"lannin$ in the <nited States. )lin ,n&e(t Dis. 200H24'!919&92A.1
Ne8 9or3 Cit!- Fho$as 8arle/, MD, MP=, ?e2 Oor5 )it/ =ealth
)o$$issioner, said, A@eDre seein% essentiall/ no 0<+1 disease
trans$itted in the )it/. @e had B50,000 to 1 $illion si(5 people last
sprin%. @e 2ere the hardest hit (it/ then, so 2e ha9e a lot o& i$$+ne
people no2.A 0)artocollis A, 7c0eill BJ Jr . Areas hit hard by fu in
s"rin$ see little now. ?e2 Oor5 Fi$es. 6ctober H, 2009;se(t *1.1
,he cat- Fhe *$eri(an Keterinar/ *sso(iation has reported a
la!orator/#(on:r$ed (ase o& =1?1 in a (at. Fhe in&e(tion 2as
pres+$a!l/ a(E+ired &ro$ a ho+sehold $e$!er, !e(a+se the (at did
not %o o+tdoors. Fhe dia%nosis 2as $ade !/ a !ron(hial la9a%e. Fhe
(at 2as treated 2ith <+ids and anti!ioti(s and re(o9ered. Fhe (at
2as des(ri!ed !/ the 9eterinarian as A(har$in% 2ith a lot o&
personalit/.A 0,arker&,o"e ;. ;he cat $ot swine fu. ;he 0ew Kork
;i%es. 0oe%ber A, 2009. Aailable at!
htt"!##well.blo$s.nyti%es.co%#2009#11#0A#the&cat&who&$ot&swine&fu#
Accessed 0oe%ber 19, 2009.1
Homeless persons and homeless shelters- /Scott 7. ,ande%ic
infuen.a $uidance -or ho%eless shelters and ho%eless serice
"roiders, 2009. Aailable at! www.nhchc.or$#fu%anual."d-
Accessed 0oe%ber 1H, 2009.1
Fhe %+idan(e is &or ho$eless shelters and ho$eless ser9i(e
pro9iders.
,solation re(o$$endations:
=o+se the si(5 person in a sin%le roo$: 011 Do not allo2 %ro+p
a(ti9it/; 021 Fhe si(5 person $+st 2ear a $as5 2hen lea9in% the
roo$; 031 ?o 9isitors +ntil the si(5 person is a&e!rile &or 2C
ho+rs; 0C1 =a9e $eals deli9ered or ha9e $eals at a diMerent
ti$e or pla(e; and 051 Pro9ide a((ess to <+ids, tiss+es,
2aste!as5et, and hand sanitier.
,& a sin%le roo$ is not a9aila!le, ho+se the si(5 person in a lar%e,
2ell#9entilated roo$ 2ith the &e2est n+$!er o& other residents
and: 011 Fr/ to separate the si(5 person &ro$ residents 2ho ha9e
ris5s &or in<+ena (o$pli(ations; 021 ,n(rease spa(in% !et2een
!eds to " &eet; 031 Use sheets or (+rtains to (reate !arriers; 0C1
Pro9ide a((ess to 2ater, soap, hand sanitier, et(. and 051 Fea(h
hand h/%iene and (o+%h etiE+ette.
'linical -eatures of H1N1 Influenza
Ty"ical $igns and $ym"toms
Fhe in(+!ation period &or =1?1 in<+ena is 1#C da/s, possi!l/ as lon%
as B da/s. Fhe (lini(al &eat+res o& in<+ena are 2ell 5no2n and
in(l+de:
;+dden onset o& &e9er 0+s+all/ hi%h1;
=eada(he;
-'tre$e tiredness;
Dr/ (o+%h;
;ore throat;
.+nn/ nose; and
M+s(le a(hes and sto$a(h s/$pto$s ## $ore (o$$on in (hildren.
0CBC. Interi% $uidance -or clinicians on identi-yin$ and carin$ -or
"atients with swine&ori$in infuen.a A /)1011 irus in-ection. June
2009. Aailable at!
htt"!##www.cdc.$o#h1n1fu#identi-yin$"atients.ht% Accessed
Se"te%ber 1', 2009.1
Fhe s/$pto$s o& pande$i( =1?1 in<+ena o& 2009 are essentiall/
the sa$e as the seasonal <+, altho+%h so$e ha9e noted an
in(reased &reE+en(/ o& %astrointestinal s/$pto$s, in(l+din% 9o$itin%
and diarrhea, and others ha9e noted the a!sen(e o& &e9er in a
si%ni:(ant n+$!er 2ith 9irolo%i(all/ pro9en (ases.
Fhe )D) de:nes (ases as infuen.a&like illness 0,6,1 i& there is &e9er o&
P100Q 8 03B.3Q )1 pl+s (o+%h and/or sore throat in the a!sen(e o& a
5no2n (a+se other than in<+ena. *nother (ate%or/ is acute
res"iratory illness 0*.,1, de:ned !/ the presen(e o& 2 o& the &ollo2in%
C s/$pto$s: &e9er, (o+%h, sore throat, or rhinorrhea. ,n the o+t!rea5
o& pande$i( in<+ena in ?e2 Oor5 )it/, 957 o& 9irolo%i(all/ pro9en
(ases satis:ed the ,6, de:nition. 0CBC. Swine&ori$in infuen.a A
/)1011 irus in-ections in a school && 0ew Kork City, A"ril 2009.
MM@. Mor! Mortal @5l/ .ep Dispat(h. 20092AH!1&3. Aailable at!
htt"!##www.cdc.$o#%%wr#"reiew#%%wrht%l#%%AHd0430a1.ht%
Accessed Se"te%ber 2A, 2009.1
Patients 2ith 2009 in<+ena * =1?1 in&e(tions ha9e hi%her rates o&
%astrointestinal s/$pto$s and la(5 o& &e9er (o$pared 2ith those
2ho ha9e seasonal <+. Most patients ha9e $ild s/$pto$s, !+t a
s$all s+!set o& pre9io+sl/ health/ /o+n% ad+lts ha9e se9ere
p+l$onar/ disease that pro%resses to a(+te respirator/ distress
s/ndro$e 0*.D;1; this $a/ o((+r 2ith or 2itho+t +nderl/in%
(onditions. )D) epide$iolo%ist Fi$ U/e5i notes that a!o+t 127 do
not ha9e &e9er and that $an/ report diarrhea and 9o$itin%.
7!mptoms in 2iroloicall! con:rmed cases- D+rin% an o+t!rea5
o& =1?1 in a ?e2 Oor5 )it/ hi%h s(hool, a sa$ple o& ?e2 Oor5 )it/
s(hool st+dents 0$edian a%e, 15 /ears1 2ith 9irolo%i(all/ (on:r$ed
(ases 2ere inter9ie2ed a!o+t their s/$pto$s !/ telephone. Fhe/
reported:
)o+%h 09371;
;+!Ge(ti9e &e9er 09"71;
8ati%+e 03971;
=eada(he 03271;
;ore throat 03271;
*!do$inal pain 05071;
Diarrhea 0C371;
D/spnea 0C371; and
Joint pain 0C"71.
Fhe $eas+red $ean pea5 &e9er in this %ro+p 2as 102.2Q 8. 0CBC.
Swine&ori$in infuen.a A /)1011 irus in-ections in a school && 0ew
Kork City, A"ril 2009. MM@. Mor! Mortal @5l/ .ep Dispat(h.
20092AH!1&3. Aailable at!
htt"!##www.cdc.$o#%%wr#"reiew#%%wrht%l#%%AHd0430a1.ht%
Accessed Se"te%ber 2A, 2009.1
$.ine -lu( 1 /iller% 0 1uestions
/7aher F, Futler B. Swine fu! 6ne killer irus, three key Luestions.
0ature. 200924'2!1A4&1A7.1
*n arti(le in 0ature &eat+red onsite inter9ie2s 2ith leadin%
in9esti%ators in 3 distin(t resear(h areas. =ere is a s+$$ariation:
;uestion 1: Ho8 does it 3ill< ;heri& Ha5i &ro$ the )D) ans2ered,
sa/in% that pande$i( * =1?1 !inds the re(eptors in the ter$inal
al9eoli o& the l+n%s. Fhis is not a (hara(teristi( o& seasonal <+, 2hi(h
pre&erentiall/ in&e(ts +pper air2a/ (ells. Fhe pattern o& 2009 *
0=1?11 is o&ten seen 2ith a9ian in<+ena 0=5?11, !+t it is des(ri!ed
as $ore se9ere 2ith =1?1 ## Ali5e a9ian <+ on steroids.A
;uestion 2: Ho8 does it transmit< *+thorities Peter Palese, John
;teel, and *ni(e 6o2en at Mo+nt ;inai ;(hool o& Medi(ine re9ie2ed
their data 0p+!lished in Jo+rnal o& Kirolo%/ last $onth1 !ased on
%+inea pi% e'peri$ents. ,n&e(ted ani$als in 2ire (a%es trans$itted
the 9ir+s to pre9io+sl/ +nin&e(ted %+inea pi%s in adGa(ent (a%es,
indi(atin% aerosol trans$ission as 2ith seasonal <+.
;uestion &: =hat could it turn into< Fhis 2as as5ed o& Br+no
6ina &ro$ Uni9ersitR )la+de Bernard 6/on, 2or5in% at the Biose(+rit/
6e9el#C la!orator/ at ,?;-.M 0?ational Medi(al .esear(h ,nstit+te1 in
Paris. Fhe resear(hers 2ant to test reassortants to :nd deter$inants
o& 9ir+len(e and trans$issi!ilit/, !+t this 2or5 reE+ires ri%oro+s
s(ienti:( re9ie2 to deter$ine p+!li( health G+sti:(ation. 4ne ai$ is
to deter$ine the reassort$ent potential &or (o$!inin% the 9ir+len(e
o& =5?1 and the trans$issi!ilit/ o& =1?1.
'ase #efinitions for H1N1 Influenza
0CBC. Interi% $uidance -or clinicians on identi-yin$ and carin$ -or
"atients with swine&ori$in infuen.a A /)1011 irus in-ection. June
2009. Aailable at!
htt"!##www.cdc.$o#h1n1fu#identi-yin$"atients.ht% Accessed
Se"te%ber 1', 2009.1
Con>r%ed case! Patient 2ith ,6, pl+s la!orator/ e9iden(e (on:r$ed
!/ real#ti$e .F#P). or 9iral (+lt+re;
,robable case! ,6, pl+s la!orator/ test positi9e &or in<+ena * and
ne%ati9e &or h+$an =1 and =3 !/ .F#P).; and
6"tional! ,6, 2itho+t ne%ati9e =1?1 test and 011 pre9io+sl/ health/
person J "5 /ears hospitalied &or ,6,; 021 epide$iolo%i( lin5 to
(on:r$ed or pro!a!le (ase in past B da/s; or 031 ,6, pl+s tra9el
to a state or (o+ntr/ 2ith (on:r$ed or pro!a!le (ases.
'om"lications of H1N1 Influenza
-'a(er!ation o& +nderl/in% (hroni( disease;
)o$pli(ations related to the +pper air2a/s, in(l+din% sin+sitis or
otitis;
P+l$onar/ (o$pli(ations, in(l+din% !ron(hitis, asth$a 0so$eti$es
2ith stat+s asth$ati(+s1, and a(+te e'a(er!ations o& (hroni(
!ron(hitis; and
Mis(ellaneo+s (onditions, in(l+din% (ardia( 0$/o(arditis and
peri(arditis1, $/ositis, rha!do$/ol/sis, (entral ner9o+s s/ste$
(o$pli(ations 0en(ephalopath/, en(ephalitis, sei+res1, to'i(
sho(5 s/ndro$e, and se(ondar/ !a(terial pne+$onia.
6acterial coin>ections- )D) in9esti%ators re9ie2ed (lini(al re(ords
and patholo%/ reports &ro$ BB lethal (ases o& pande$i( =1?1
in&e(tion. 0CBC. Facterial coin-ections in lun$ tissue s"eci%ens -ro%
-atal cases o- 2009 "ande%ic infuen.a A /)1011 & <S, 7ay & Au$ust
2009. MM@. Mor! Mortal @5l/ .ep. 20092AH! early release1 Fhe
tiss+e spe(i$ens 2ere e'a$ined !/ tiss+e Gra$ stain, @arthin#
;tarr/ sil9er stain, 9ario+s $i(ro!e#spe(i:( i$$+nohisto(he$i(al
assa/s, and P). that tar%eted the 1"; ri!oso$al D?* in tiss+e
!lo(5s. Ba(teria 2ere dete(ted in 22 o& BB (ases 02971. MaGor
patho%ens 2ere Stre"tococcus "neu%oniae 0101, Sta"hylococcus
aureus 0B1, Stre"tococcus "yo$enes 0"1, Stre"tococcus %itis 021, and
)ae%o"hilus infuen.ae 011; C (ases had $ore than 1 patho%en. Fhe
st+d/ a+thors e$phasie the i$portan(e o& !a(terial s+perin&e(tion
in patients 2ith in<+ena. D+rin% the 1913#19 pande$i(, $ost
deaths 2ere asso(iated 2ith !a(terial s+perin&e(tion. /7orens BS,
;aubenber$er J(, Cauci AS. ,ro%inent role o- bacterial "neu%onia as
a cause o- death in "ande%ic infuen.a! i%"lications -or "ande%ic
infuen.a "re"aredness J ,n&e(t Dis. 2003;193:9"2#9B0.1
7e2ere complications o> H1N1 Infuenza- ,n J+ne 2009, the
Uni9ersit/ o& Mi(hi%an reported se9ere p+l$onar/ (o$pli(ations o&
2009 =1?1 in<+ena in&e(tion in 10 patients 2ith a $edian a%e o& C9
/ears. *ll 10 patients 2ere re&erred &or se9ere h/po'e$ia, *.D;, and
ina!ilit/ to o'/%enate 2ith (on9entional 9entilation $ethods. *ll had
se9ere $+ltilo!ar pne+$onia on '#ra/, none had e9iden(e o&
!a(terial pne+$onia, and C had )F s(an#(on:r$ed p+l$onar/
e$!olis$. 6a! :ndin%s in(l+ded le+5o(/tosis in 5 0$edian @B)
9500/$$
3
1, ele9ated *;F le9els 0C1#109 ,U/61 in all 10, and ele9ated
)PL le9els 051#"5B2 ,U/61 in "; none had e9iden(e o& disse$inated
intra9as(+lar (oa%+lation. Fhe $aGor ris5 &a(tor 2as o!esit/ in 9 and
$or!id o!esit/ 0BM, J C01 in B. *ll 10 reE+ired ad9an(ed $e(hani(al
9entilation 2ith hi%h#&reE+en(/ os(illator/ or !ile9el 9entilation 2ith
$ean air2a/ press+res o& 32#55 ($ =
2
4. F2o reE+ired 9eno#9eno+s
e'tra(orporeal $e$!rane o'/%enation 0-)M41 s+pport and "
reE+ired dial/sis. *t the ti$e o& the report, 3 had died, 1 2as still on
-)M4, 1 2as still on $e(hani(al 9entilation, and 5 had !een
trans&erred !a(5 to re&errin% instit+tions. 0CBC. Intensie care
"atients with seere noel infuen.a A /)1011 irus in-ection &&
7ichi$an, June, 2009. MM@. Mor! Mortal @5l/ .ep. 20092AH!749&
7A2.1
Neuroloic complications- ?e+rolo%i( (o$pli(ations 2ere reported
in C (hild#ren a%es B#1B /ears 2ith 2009 =1?1 in<+ena *. 8indin%s
in(l+ded sei+res in 2 (hildren, en(ephalitis in 2, and ata'ia in 1. *ll
re(o9ered 2itho+t ne+rolo%i( seE+elae. Fhe editorial (o$$ent in this
report noted that the ne+rolo%i( disease in these C patients 2as less
se9ere than 2hat has !een des(ri!ed in pre9io+s reports o& seasonal
<+. 0CBC. 0eurolo$ical co%"lications associated with noel infuen.a
A /)1011 in-ection in children && Ballas, ;e9as, 7ay 2009. MM@.
Mor! Mortal @5l/ .ep. 20092AH!773&77H.2 7aricich S7, 0eu- JI, Iot.e
;E, et al. 0eurolo$ic co%"lications association with infuen.a A in
children durin$ the 2003&2004 infuen.a season in )ouston, ;e9as.
Pediatri(s. 20042114!e'2'&e'33.2 7orishi%a ;, ;o$ashi ;, Kokota S, et
al. Ence"halitis and ence"halo"athy associated with an infuen.a
e"ide%ic in Ja"an. )lin ,n&e(t Dis. 200223A!A12&A17.1
,elated ,is2 for Infection% Hos"italization% and 3ethal
4utcome
'e-related ris3- Fhese data are sho2n in Fa!le 3.
,a"le &- /ates >or H1N1 >or %a!-Jul! 2009 "! 'e
'e Cases5100$000 Hospitalization5100$000
0#C /rs 23
5#2C /rs 2B
25#C9 /rs B
50#"C /rs C
J "5 /rs 1.3
a
7 o& total deaths. *%e data not a9aila!le &or 157. .ate e'pressed /
100,000 pop+lation
.7 ae data
00oel Swine&6ri$in Infuen.a A /)1011 Dirus Inesti$ation ;ea%2
Bawood CS, Jain S, Cinelli I, et al. E%er$ence o- a noel swine&ori$in
infuen.a A /)1011 irus in hu%ans. ? -n%l J Med. 200923'0!2'0A&
2'1A.1
Median a%e o& (on:r$ed (ases: 12 /ears
Median a%e o& hospitalied (ases: 20 /ears
Median a%e o& lethal (ases: 3B /ears
* (o$parison o& the =1?1 o+t(o$e and seasonal <+ o+t(o$e in
elderl/ indi9id+als is sho2n in Fa!le C.
,a"le #- 'e-/elated +utcome =ith 2009 H1NI Infuenza
Compared =ith 7easonal Infuenza in the .nited 7tates?
Hospitalized
'e @ () !rs
;easonal <+
2009 =1?1
"07
57
S)D). Use o& in<+ena * 0=1?11 2009 $ono9alent 9a((ine ###
re(o$$endations o& the *d9isor/ )o$$ittee on ,$$+niation
Pra(ti(es 0*),P1, 2009. 77*+ 7orb 7ortal *kly +e". 2009;530..#
101:1.)D). Update: ;2ine#ori%in in<+ena * 0=1?11 9ir+s ### United
;tates and other (o+ntries. 77*+ *kly. 2009;53:C21.
Fhe +n+s+al a%e distri!+tion o& 2009 =1?1 9ir+s in&e(tion is
attri!+ted to st+dies sho2in% that persons 2ho 2ere e'posed to the
1913 in<+ena 9ir+s ha9e anti!od/ to 2009 =1?1 strains. .elated
=1?1 in<+ena strains (ir(+lated +ntil 195B, s+%%estin% that people
!orn !e&ore this ti$e 2ere li5el/ to !e e'posed to (o$$on anti%ens.
=1?1 9ir+ses re#e$er%ed in 19BB and 2ere anti%eni(all/ related to
9ir+ses (ir(+latin% in the 1950s, !+t there is not %ood e9iden(e o&
prote(tion &ro$ the 2009 =1?1 9ir+s. 0Itoh K, Shinya (, (iso 7. In
itro and in io characteri.ation o- new swine&ori$in )101 infuen.a
iruses. ?at+re. 200924'0!1021&102A.1
Estimates o> the pre2alence o> pandemic AH1N1B- /+eed C,
An$ulo CJ, Swerdlow BI, et al. Esti%ates o- the "realence o-
"ande%ic /)1011 2009, <nited States, A"ril&July, 2009. E%er$ In-ect
Bis. 2009 Bec. ME"ub ahead o- "rintN Aailable at!
htt"!##www.cdc.$o#eid#content#1A#12#"d-s#09&1413."d- Accessed
0oe%ber 4, 2009.1 Pre9io+s reports o& the pre9alen(e o& =1?1
serio+sl/ +nderesti$ated the tr+e n+$!er o& la!orator/#(on:r$ed
(ases. ,n the (+rrent st+d/, in9esti%ators &ro$ the )D) +sed Aa
si$ple $+ltiplier $odelA to (orre(t &or this. Usin% this approa(h, the
ne2 esti$ate is B9 (ases &or e9er/ la!orator/#(on:r$ed (ase, 2ith a
907 pro!a!ilit/ ran%e o& CB#1C3. Fhe $edian esti$ate &or the United
;tates d+rin% the period *pril#J+l/ 2009 2as 3 $illion s/$pto$ati(
(ases 0ran%e, 1.3#5.B $illion1. 8or hospitalied patients the $+ltiplier
2as 2.B, /ieldin% a $edian o& 1C,000 09000#21,0001, 2ith a 907
pro!a!ilit/ ran%e o& 1.9#C.3. )ases and rates !/ a%e are pro9ided in
Fa!le 5.
,a"le )- Estimated Cases and /ates o> 2009 Infuenza '
AH1N1B in the .nited 7tates >or 'pril-Jul! 2009
'e Cases A%edianB
/ate5100$000
0opulation
A%edianB
Cases
AC
1000B
?
Hospitaliz
ed
AC 1000B?
Case
s Hospitalized
Fotal 3052 13 99B C.5
0#C
/ears
39B 2.B 13B0 13.0
5#2C
/ears
1320 C.9 219" ".0
25#C9
/ears
"12 3.C 5BB 3.2
50#"C
/ears
130 1.9 319 3.C
P "5
/ears
C2 0." 10B 1.B
O0u%bers rounded -or table /+eed C, An$ulo CJ, Swerdlow BI, et al.
Esti%ates o- the "realence o- "ande%ic /)1011 2009, <nited
States, A"ril&July, 2009. -$er% ,n&e(t Dis. 2009 Bec. ME"ub ahead o-
"rintN Aailable at! htt"!##www.cdc.$o#eid#content#1A#12#"d-s#09&
1413."d- Accessed 0oe%ber 4, 2009.1
5ediatric Hos"italizations
Data &ro$ a re9ie2 o& C"5 pediatri( hospitaliations &or the period
*pril 15# *+%+st 31, 2009 are s+$$aried in Fa!le ".
,a"le (- .nderl!in Conditions in Children Hospitalized >or
H1N1 Infuenza
Condition N ADB
J 1 +nderl/in%
(ondition
C"5 0"271
*sth$a 1"" 03"71
De9elop$ental dela/ 33 0B71
=e$o%lo!inopath/ 31 0B71
;ei+re disorder 2B 0"71
Pre$at+rit/ 2B 0"71
?e+ro$+s(+lar
disease
2C 0"71
)hroni( l+n% disease 23 0571
,$$+nos+ppression 21 0C71
)ardio9as(+lar
disease
20 0C71
)hroni( $eta!oli(
disease
1C 0371
/CBC. In-or%ation on )101 infuen.a and )101 accination and
treat%ent -or children. Clinician 6utreach and Co%%unication
Actiity Con-erence Call. 6ctober 2H, 2009.1
5ediatric #eaths
8or in<+ena 2ee5 C2 0endin% 4(to!er 2C, 20091:
Fo date, the )D) data &or pediatri(s sho2 BC pediatri( deaths &ro$
in<+ena in the 2009#2010 season. )o$parati9e data &or 200"#200B,
200B#2003, and 2003#2009 seasons sho2 that the total n+$!er o&
pediatri( deaths 2as 11B, 33, and B3, respe(ti9el/. /CBC. 2009&2010
infuen.a season week 42 endin$ 6ctober 24, 2009. CluDiew.
Aailable at! htt"!##www.cdc.$o#fu#weekly# Accessed 0oe%ber 1,
2009.1
'es o> patients hospitalized >or infuenza 0all t/pes1 &or the
period ;epte$!er 1, 2009#4(to!er 2C, 2009 appear in Fa!le B.
,a"le *- 'e o> 0atients Hospitalized >or Infuenza
'e
Infuenza /ate
Aper 10$000B
0#C /ears 2.B 0C.91
5#1B /ears 1.3 02.51
13#C9 /ears 0.9 00.31
50#"C /ears 1.0 00.91
J "5 /ears 0.3 00.B1
D+rin% the period Ma/ 11#4(to!er 11, 2009, T+est Dia%nosti(s
tested B",500 spe(i$ens &ro$ hospitalied patients, !/ &ar the
lar%est so+r(e o& =1?1 testin% data. .es+lts sho2 that 537 o&
patients 2ere /o+n%er than 25 /ears o& a%e, and B7 o& patients 2ere
older than "5 /ears o& a%e. Fhere 2as a sharp rise in s(hool#a%e
(hildren 2ith in<+ena in ;epte$!er, and se9eral 2ee5s later
in<+ena in(reased in the elderl/, persons 50#"C /ears o& a%e, and
(hildren /o+n%er than 5 /ears o& a%e. Fhis te$poral relationship
s+%%ests 2hat $i%ht !e e'pe(ted epide$iolo%i(all/ in +p(o$in%
2ee5s. Fhe report e$phasies the need to 9a((inate (hildren &or
their o2n health and to slo2 the epide$i(. /Co9 7. ;ests show fu
s"reads -ro% schools. +euters. 6ctober 21, 2009. Aailable at!
htt"!##www.reuters.co%#article#health0ews#id<S;+EA9(3S92009102
1 Accessed 0oe%ber 4, 2009.
/is3s >or serious disease reEuirin hospitalization or causin
death
0renanc! and 2009 infuenza ' AH1N1B- 4ne h+ndred pre%nant
2o$en 2ith s2ine <+ ha9e !een hospitalied in ,)Us; 23 o& these
2o$en died. 0CBC ,ress Frie>n$ ;ranscri"ts. *eekly 2009 )101 Clu
7edia Frie>n$. 6ctober 1, 2009. Aailable at!
htt"!##www.cdc.$o#%edia#transcri"ts#2009#t091001.ht% Accessed
6ctober 22, 2009.1
Pre%nan(/: * re9ie2 o& 3C (on:r$ed (ases o& 2009 =1?1 in<+ena
in pre%nant 2o$en, reported to the )D) &ro$ 13 states, sho2ed
that 11 2o$en 2ere hospitalied and " died. *ll " deaths 2ere
in pre9io+sl/ health/ 2o$en 2ho de9eloped 9iral pne+$onia
and *.D; reE+irin% $e(hani(al 9entilation. ?one o& the 5
in&ants !orn to these 2o$en had e9iden(e o& in<+ena.
/Ja%ieson BJ, )onein 7A, +as%ussen SA, et al. )101 2009
infuen.a irus in-ection durin$ "re$nancy in the <SA. 6an(et.
20092374!4A1&4AH.1
4ther pre9io+sl/ de:ned ris5s 0(hroni( +nderl/in% disease or
i$$+nos+ppressed1 in 11B/1B9 0"571 o& hospitalied patients;
4!esit/: 307#357 o& hospitalied patients are o!ese 0BM, P 301 or
$or!idl/ o!ese 0BM, J C01. ?ote that 257 o& ad+lts in the
United ;tates are o!ese !/ this de:nition and that $ost o& the
o!ese patients hospitalied 2ith =1?1 had other predisposin%
illnesses. ?e9ertheless, a rodent $odel sho2ed e'(essi9e
$ortalit/ in a %ro+p o& $i(e &ed 2ith a hi%h#&at diet. /S%ith AJ,
Sheridan ,A, ;sen$ +J, Sheridan JC, Feck 7A. Selectie
i%"air%ent in dendritic cell -unction and altered anti$en&
s"eci>c CBHP ;&cell res"onses in diet&induced obese %ice
in-ected with infuen.a irus. ,$$+nolo%/. 2009212'!2'H&279.1
0atients hospitalized 8ith 2009 H1N1 infuenza in the .nited
7tates- Fhe )D) re9ie2ed the $edi(al re(ords &ro$ 2B2 o& the 1032
patients hospitalied 2ith in<+ena as reported to the )D) &or the
period Ma/ 1, 2009 to J+ne 9, 2009. /Jain S, (a%i%oto I, Fra%ley
A7, et al. )os"itali.ed "atients with 2009 )101 infuen.a in the
<nited States, A"ril&June, 2009. ? -n%l J Med. 2009 3'1!93A&944.1
,$portant o!ser9ations &ro$ this re9ie2:
,)U patients &all into 3 (ate%ories:
Pri$ar/ in<+ena pne+$onia 2ith se9ere %as e'(han%e
a!nor$alities;
,n9asi9e !a(terial s+perin&e(tion +s+all/ (a+sed !/ ; a+re+s
0in(l+din% $ethi(illin#resistant S aureus1, S "neu%oniae, and
%ro+p * strepto(o((+s; and
@orsenin% or%an d/s&+n(tion as a res+lt o& poor (ardiop+l$onar/
reser9e as a (onseE+en(e o& (o$or!idities.
*%e distri!+tion: $edian a%e: 21 /ears; 1C patients 2ere older than
"5 0571;
;/$pto$s: 9o$itin% or diarrhea: 397;
*sso(iated (onditions: an/: 193 0B371; asth$a: B" 02371;
i$$+nos+ppression: C0 01571; pre%nan(/: 13 0B71; $or!id
o!esit/ in ad+lts 2"/100 02"71;
6a!: '#ra/ sho2in% pne+$onia: 100/2C9 0C071 in(l+din% "0/100
2ith !ilateral in:ltrates; ane$ia: 3B/233 03B71; le+5openia:
50/2C" 02071; !a(tere$ia: 3/2B2 0171;
,)U ad$ission: "B 02571;
Mortalit/: 19 0B71 ## all 2ere ,)U patients %i9en $e(hani(al
9entilation; $edian a%e 2as 2" /ears; $edian ti$e &ro$ onset
to death 2as 15 da/s; +nderl/in% disease present in 13/19
0"371;
*nti$i(ro!ials: anti9iral a%ents 2ere %i9en to 201/2"3 0B571
startin% at a $edian o& 3 da/s a&ter onset o& illness; anti!ioti(s
2ere %i9en to B97;
?e+ra$inidase inhi!itor treat$ent has !een asso(iated 2ith
in(reased s+r9i9al;
Fhe report notes that oselta$i9ir or ana$i9ir is re(o$$ended &or
patients hospitalied 2ith in<+ena and &or those at hi%h ris5 &or
(o$pli(ations, e9en i& started later than C3 ho+rs a&ter onset o&
s/$pto$s. /7cJeer A, Jreen (A, ,leneshi A, et al. Antiiral
thera"y and outco%es o- infuen.a reLuirin$ hos"itali.ation in
6ntario, Canada. )lin ,n&e(t Dis. 200724A!1A'H&1A7A.1
7ur2eillance o> patients hospitalized 8ith H1N1 infuenza
Most ad+lts ha9e asso(iated ris5s, espe(iall/ asth$a, (hroni( l+n%
or heart disease, or i$$+nos+ppression;
Most (hildren ha9e asso(iated ris5s s+(h as asth$a, (hroni( l+n%
disease, ne+rolo%i( disease, or si(5le (ell disease; and
"7 2ere pre%nant 2o$en
Factors associated 8ith death or hospitalization >rom
pandemic 2009 infuenza ' AH1N1B in>ection in Cali>ornia-
Ba(5%ro+nd: Pande$i( in<+ena * 0=1?11 e$er%ed rapidl/ in *pril
2009. Fhe preli$inar/ i$pression is that, (o$pared 2ith
seasonal <+, it aMe(ted /o+n%er people and 2as +s+all/ $ild.
Goal: Des(ri!e the (lini(al and epide$iolo%i( &eat+res o& this
in<+ena that led to death or hospitaliation.
Method: -nhan(ed p+!li( health s+r9eillan(e o& )ali&ornia residents
2ho 2ere hospitalied or died 2ith la!orator/#(on:r$ed
in&e(tion 2ith 2009 ,n<+ena * 0=1?11 &ro$ *pril 23, 2009 to
*+%+st 11, 2009.
.es+lts: Data are !ased on 1033 (ases o& hospitaliation or death
reported in C1 o& "1 lo(al health G+risdi(tions, 2ith $ost
o((+rrin% in the :rst 2a9e d+rin% J+ne and J+l/.
;ee Fa!le 3.
,a"le F- Characteristics and Comor"id Conditions o>
Hospitalized and Fatal Cases o> 2009 Infuenza ' AH1N1B in
Cali>ornia

'e 0-1*
!ears 'e G 1F !ears
4aria"le
,otal
n H 10FF
Fatal
F
Non>ata
l
&&(
Fatal
110
Non>ata
l
(&#
7ins5s!mptoms
8e9er
D/spnea
)hills
Diarrhea
?a+sea/9o$itin%
397
5"7
207
207
357
100
7
337
07
257
507
957
337
B7
197
337
337
317
257
137
207
3B7
"37
2B7
207
3B7
Ia"orator!
Positi9e rapid <+ test
,n:ltrates 0'#ra/1
""7
""7
337
307
357
"07
CC7
9B7
597
"27
Hospital Care
,)U
Me(hani(al
9entilation
*nti9iral therap/
Ba(terial in&e(tion
317
257
B97
C7
B57
337
"37
137
257
107
BB7
27
307
937
B37
1C7
2"7
197
327
C7
'ssociated
conditions
)hroni( l+n% disease
*sth$a
Dia!etes
Pre%nan(/
,$$+nos+ppressi9e
dr+%s
=,K/*,D;
+ther premor"id
conditions
BM, J 30
BM, J C0
)hroni( heart
disease
BC3 0"371
3B7
2C7
117
107
1C7
27
3B0 03C71
C37
C37
157
"
0B57
1
337
137
07
07
257
07
2
0257
1
07
####
257
199
05971
337
297
17
27
137
07
C5
01371
197
####
B7
33
0B571
C17
1"7
137
"7
2"7
C7
"9
0"371
""7
507
237
C53
0B171
3"7
227
1C7
157
137
37
25C
0C071
527
C07
137
F7I ? body %ass inde9
,$portant o!ser9ations &ro$ this st+d/:
G, s/$pto$s 2ere noted in J 357 (o$pared 2ith I 57 in those
2ho had seasonal <+;
Fhere 2as a hi%h rate o& se9ere disease, 2ith 317 reE+irin% ,)U
(are and 257 reE+irin% $e(hani(al 9entilation;
Mortalit/ 2as 117 and +s+all/ 2as attri!+ted to 9iral pne+$onia or
a(+te respirator/ distress s/ndro$e;
Ba(terial pne+$onia 2as dia%nosed in onl/ C7;
=i%hest rate o& hospitaliation !/ a%e 2as in&ants I 1 /ear o& a%e
011.9/100,0001 9s 2.3/100,000 &or all a%e %ro+ps and
1.5/100,000 &or persons J B0 /ears o& a%e;
Fhe hi%hest &atalit/ rate 2as 137 in persons J 50 /ears o& a%e;
Mor!id o!esit/ 2as noted in C37 9s C.37 in the U; pop+lation;
327 did not ha9e a (o$or!id illness.
0Iouie J(, Acosta 7, *inter (, Jean C, et al. Cactors associated with
death or hos"itali.ation due to "ande%ic 2009 infuen.a A/)1011
in-ection in Cali-ornia J*M*. 20092302!1H9'&1902.1
,ndi9id+als sho+ld see5 e$er%en(/ $edi(al (are i& the/ ha9e
d/spnea, (hest pain or press+re, (on&+sion or sei+res, persistent
9o$itin%, or !l+ish lips. /CBC. )101 fu /swine fu1! $eneral
in-or%ation, 2009. Aailable at!
htt"!##www.cdc.$o#h1n1fu#$eneral8in-o.ht% Accessed Se"te%ber
1', 2009.1
,is2 ,eduction ,ecommendations for $"ecific 5atient 6rou"s
/Clu.$o. ,eo"le with health conditions. Aailable at!
htt"!##"ande%icfu.$o#indiidual-a%ily#healthconditions#inde9.ht%l
Accessed 6ctober 2', 2009.1
'sthma
Get 9a((inated &or seasonal <+ as soon as the 9a((ine is a9aila!le.
)hildren a%es " $onths to 3 /ears 2ho ha9e ne9er had seasonal
<+ 9a((ine need 2 doses.
Persons " $onths to "C /ears o& a%e sho+ld %et the 2009 =1?1
9a((ine !/ inGe(tion as soon as it is a9aila!le 2here the/ li9e
Persons 2ith asth$a sho+ld not ta5e the intranasal 08l+Mist1
9a((ine.
4selta$i9ir is re(o$$ended &or patients 2ith asth$a 2ho %et 2009
=1?1 in&e(tion; it sho+ld !e started 2ithin C3 ho+rs o& onset o&
s/$pto$s i& possi!le.
1ia"etes
Patients 2ith dia!etes sho+ld %et !oth seasonal <+ 9a((ine and
=1?1 9a((ine.
Dia!etes (are: )ontin+e ins+lin or oral h/po%l/(e$i(s e9en i& the
patient (annot eat; $onitor !lood %l+(ose e9er/ C ho+rs and
re(ord; drin5 e'tra (alorie#&ree liE+ids; 2ei%h dail/.
=ealth pro9ider sho+ld !e alerted &or te$perat+re J 100Q8, !lood
%l+(ose I "0 $%/d6 or J 300 $%/d6, $oderate or lar%e a$o+nt
o& +rine 5etones, (han%e in $ental stat+s, d/spnea, 2ei%ht loss
o& 5 l!s or $ore, or onset o& se9ere diarrhea.
0renanc!
Pre%nant 2o$en are at hi%h ris5 &or serio+s in<+ena
(o$pli(ations.
Pre%nant 2o$en sho+ld %et !oth seasonal <+ 9a((ine and 2009
=1?1 <+ 9a((ine, !oth !/ ,M inGe(tion 2hen the 9a((ines
!e(o$e a9aila!le. Pre%nant 2o$en sho+ld not %et the
intranasal 6*,K 08l+Mist1 9a((ine.
Pre%nant 2o$en 2ith esta!lished or s+spe(ted in<+ena sho+ld !e
treated 2ith oselta$i9ir or ana$i9ir, pre&era!l/ 2ithin 2 da/s o&
the onset o& s/$pto$s.
7tatins and reduced death >rom infuenza- /Dander%eer 7,
;ho%as A, (a%i%oto I, et al. ,ro$ra% and abstracts o- the 47th
In-ectious Biseases Society o- A%erica Annual 7eetin$2 6ctober 29&
0oe%ber 1, 20092 ,hiladel"hia, ,ennsylania. Abstract 70'.1 Fhe
a+thors re9ie2ed 2300 patients older than 13 /ears 2ho 2ere
hospitalied 2ith in<+ena d+rin% the 200B#2003 season, +sin% a
s+r9eillan(e s/ste$ that (o9ered 10 states. Fhe $ortalit/ rate 2as
red+(ed !/ 5C7 in patients 2ho re(ei9ed statins &or (ardio9as(+lar
disease. 0;ee ne't re9ie21
,reatin the Jc!to3ine stormJ o> infuenza- /Cedson BS.
Con-rontin$ the ne9t infuen.a "ande%ic with anti&infa%%atory and
i%%uno%odulatory a$ents! *hy they are needed and how they
%i$ht work. Infuen.a 6ther +es"i Diruses. 200923!129&1421. Fhe
a+thor re9ie2s data &ro$ $+ltiple so+r(es s+pportin% the thesis that
a(+te l+n% inG+r/ that is asso(iated 2ith in<+ena is (a+sed !/
e'(essi9e release o& (/to5ines, the A(/to5ine stor$.A Fhis is seen
2ith the e'peri$ental $odels o& the 1913#1919 pande$i( strain,
=5?1 0a9ian1 in<+ena, and 2009 0=1?11. *%ents that inhi!it
(/to5ine prod+(tion $a/ !e lo%i(al therape+ti( a%ents and ha9e
de$onstrated !ene:t in the $o+se $odel o& =5?1 in<+ena. /Qhen$
FJ, Chan (*, Iin K,. Belayed antiiral "lus i%%uno%odulator
treat%ent still reduces %ortality in %ice in-ected by hi$h inoculu% o-
infuen.a A#)A01 irus. ,roc 0atl Acad Sci < S A. 200H210A!H091&
H09'.1 ,t is noted that 3 (lasses o& dr+%s that 2or5 in this &ashion 0!/
inhi!itin% (ell#si%nalin% path2a/s in (/to5ine prod+(tion1 are statins,
%litaones, and :!rates. M+ltiple st+dies ha9e sho2n that the
$ortalit/ rate o& !a(terial pne+$onia is red+(ed !/ a!o+t 507 in
patients re(ei9in% statins. /Cho"ra D, Clanders SA. Boes statin use
i%"roe "neu%onia outco%es= Chest. 2009213'!13H1&13HH.1
4utcomes of Treatment in $everely Ill 5atients
Australia and Ne. 7ealand E8tracor"oreal *em9rane
48ygenation for 2! Influenza A (H1N1) Acute ,es"iratory
#istress $yndrome
/Australia and 0ew Qealand E9tracor"oreal 7e%brane 69y$enation
/A0Q EC761 Infuen.a Inesti$ators. E9tracor"oreal %e%brane
o9y$enation -or 2009 infuen.a A /)1011 acute res"iratory distress
syndro%e. JA7A. 2009 6ct 12. ME"ub ahead o- "rintN1
Fhe in9esti%ators re9ie2 their e'perien(e in 15 ,)Us in *+stralia and
?e2 Healand 2ith "3 patients 2ith 2009 in<+ena * 0=1?11 in&e(tion
2ho de9eloped a(+te respirator/ distress s/ndro$e 0*.D;1 and
reE+ired -)M4:
Patients: $ean a%e, 3C /ears; (hildren 03 (hildren /o+n%er than 15
/ears o& a%e1
Predisposin% (onditions: BM, J 30 03C patients1, asth$a 0191,
dia!etes 0101, pre%nan(/ or postpart+$ 0101
Ba(terial s+perin&e(tion 2as &o+nd in 19 patients 02371, in(l+din% S
"neu%oniae in 10 and S aureus in C
;e9erit/ o& illness: $edian 9al+es &or lo2est Pa4
2
: 5"; hi%hest
positi9e end e'pirator/ press+re 0P--P1: 13 ($ =
2
4; lo2est p=:
B.2; hi%hest 8i4
2
: 1.0; $edian a(+te l+n% inG+r/ s(ore: 3.3;
hi%hest p)4
2
: "9 $$ =%; hi%hest pea5 air2a/ press+re: 3" ($
=
2
4
)o+rse: in&e(tio+s (o$pli(ations in C2 0"271 in(l+ded respirator/
tra(t: C2; !a(tere$ia: 1C; -)M4 (ann+lae: B; and non#-)M4#
related: 13
Median d+ration o& (are $odalities: $e(hani(al 9entilation: 25
da/s; hospitaliation: 3B da/s; ,)U sta/: 2B da/s; -)M4: 10 da/s
4+t(o$e: s+r9i9al and ,)U dis(har%e: C3 0B171; s+r9i9al and
hospital dis(har%e: 32 0CB71; still in hospital: 1" 02C71; died: 1C
02171 U(a+se o& death: respirator/ &ail+re: C; intra(ranial
he$orrha%e: "; he$orrha%e: C; in&e(tion: 1 0so$e had $+ltiple
in&e(tions1V
)o$$ents:
*ll o& the patients satis:ed the )-;*. (riteria &or -)M4 0see
!elo21;
Fhe 217 end#o&#st+d/ $ortalit/ rate in this st+d/ is lo2 (o$pared
2ith pre9io+s reports; the a+thors attri!+te this to the relati9el/
/o+n% a%e o& patients and se9eral trainin% and te(hni(al
attri!+tes o& their (onsorti+$ o& -)M4 sites;
4n the !asis o& their e'perien(e, the in9esti%ators proGe(t that the
-)M4 needs &or the United ;tates and -+rope &or the 2009#2010
in<+ena season 2ill !e 300#1300 patients.
.ate o& -)M4 +se &or =1?1 in<+ena 2as 2." (ases/$illion
pop+lation in 2009 9s 0.15 (ases/$illion &or seasonal in<+ena
in 2003.
'E$A, Trial 'om"aring E'*4 and 'onventional :entilation
* st+d/ 2as desi%ned to deter$ine the sa&et/, e>(a(/, and (ost#
eMe(ti9eness o& -)M4 (o$pared 2ith (on9entional 9entilation in the
treat$ent o& ad+lts 2ith se9ere a(+te respirator/ &ail+re. Fhere 2ere
120 ad+lts 2ith potentiall/ re9ersi!le respirator/ &ail+re and M+rra/
s(ore J 3.0 or p= I B.2. Fhe "#$onth s+r9i9al 2as 5B/90 0"371 &or
patients allo(ated to (onsideration o& treat$ent !/ -)M4 9s C1/3B
0CB71 &or patients allo(ated to (on9entional treat$ent 0, W .031.
0,eek JJ, 7u$-ord 7, ;iruoi"ati +, et al. ERcacy and econo%ic
assess%ent o- conentional entilatory su""ort ersus
e9tracor"oreal %e%brane o9y$enation -or seere adult res"iratory
-ailure /CESA+1! a %ulticentre rando%ised controlled trial. 6an(et.
20092Se" 1A ME"ub ahead o- "rintN.1
'ritically Ill 5atients in 'anada
L+$ar and (ollea%+es present a prospe(ti9e o!ser9ational st+d/ o&
1"3 patients (riti(all/ ill 2ith 2009 in<+ena * 0=1?11 (ared &or in 33
ad+lt and pediatri( ,)Us in )anada d+rin% *pril 1"#*+%+st 12, 2009.
*ll patients 2ere e9al+ated !/ a standardied proto(ol.
1emoraphics- Mean patient a%e 2as 32 /ears, 2ith 50 03071
+nder 13 /ears o& a%e. Fhere 2ere 1" noso(o$ial (ases. )hroni(
pree'istin% (onditions o& the sa$ple in(l+ded:
)hroni( l+n% disease: "9 0C171, in(l+din% asth$a 033 U237V1 and
)4PD 01" U107V1;
4!esit/: 5" 03371; $or!id o!esit/ 2ith BM, J C0: 23 02C71;
,$$+ne s+ppression: 33 02071, in(l+din% (hroni( steroids 02"
U1"7V1 and =,K 02 U17V1;
?e+rolo%i( disease: 2" 01"71;
)ardia( disease: 25 01571;
Pre%nan(/: 13 0371;
Mali%nan(/: " 0C71; and
)hroni( renal disease: 12 0B71.
7!mptoms
8e9er: 917;
M/al%ias: 5"7;
;+spe(ted !a(terial in&e(tion: 327;
=/potension: 1C7;
*ltered (ons(io+sness:107;
.enal &ail+re: B7;
Median d+ration o& s/$pto$s prior to hospitaliation: C da/s;
Median d+ration o& hospitaliation prior to ,)U: 1 da/.
0h!sical eCam and la"orator! data 0da/ 1 o& hospitaliation1:
)hest '#ra/ 0!ilateral in:ltrates: B17; C#E+adrant in9ol9e$ent:
C17; l+n% inG+r/ Aat onsetA: B371;
Kital si%ns 0$ean p+lse: 119; lo2est $ean s/stoli( BP: 95 $$=%;
$ean ;48* s(ore: ".31;
6a! res+lts 0$ean @B): 9C00/$6; $edian )PL: 2C31.
,reatment
Me(hani(al 9entilation:13" 03171 on da/ 1;
Freat$ent &or 4
2
&ail+re in(l+ded ne+ro$+s(+lar !lo(5ade in CB
02371, inhaled nitri( o'ide in 23 01C71, hi%h#&reE+en(/
os(illator/ 9entilation in 20 01271, -)M4 in B 0C71, and prone#
position 9entilation in 5 0371;
Dr+%s: 9asopressors or inotropes: 55 03371; anti9irals:152 09171;
anti!a(terials: 1"" 09971; (orti(osteroids: 35 05171.
/(u%ar A, Qarychanski +, ,into +, et al. Critically ill "atients with
2009 infuen.a A/)1011 in-ection in Canada. J*M*. 2009 6ct 12.
ME"ub ahead o- "rintN1
E"idemiology of 2! H1N1
4irus- 2009 =1?1 in<+ena 9ir+s is a E+adr+ple reassort$ent 2ith
%ene prod+(ts &ro$ pi%s 0-+rope and *sia ori%in1, a9ian in<+ena,
and h+$an in<+ena strains. Fhis 9ir+s is anti%eni(all/ +nrelated to
=1?1 in<+ena 9ir+ses in (ir(+lation sin(e 195B. 0Jarten +J, Bais
C;, +ussell CA, et al. Anti$enic and $enetic characteristics o- swine&
ori$in 2009 A/)1011 infuen.a iruses circulatin$ in hu%ans. ;(ien(e.
2009232A!197&201.2 Qi%%er S7, Furke BS. )istorical "ers"ectie &&
e%er$ence o- infuen.a A /)1011 iruses. ? -n%l J Med.
200923'1!279&2HA.1
*s o& ;epte$!er 1, 2009, the =1?1 9ir+ses are si$ilar, sho2in%
$ini$al $+tation !/ seE+ential anal/sis and !/ %eo%raphi(
distri!+tion. 0CBC. ,neu%onia hos"itali.ations a%on$ youn$ children
be-ore and a-ter introduction o- "neu%ococcal con5u$ate accine &&&
<nited States, 1997&200'. MM@.. Mor! Mortal @5l/ .ep. 20092AH!1&
4.1
6a!orator/ st+dies sho2 that in the rodent $odel, (o$pared 2ith
seasonal =1?1 strains, the 2009 =1?1 9ir+s repli(ates in l+n%s $ore
e>(ientl/, (a+ses diMerent proin<a$$ator/ (/to5ine responses, and
res+lts in $ore l+n% da$a%e and $ore death. 0Itoh K, Shinya (, (iso
7. In itro and in io characteri.ation o- new swine&ori$in )101
infuen.a iruses. ?at+re. 200924'0!1021&102A.1
,ransmission rates
.eprod+(tion ratio 0.
4
1 W 1.C
;e(ondar/ atta(5 rates in ho+seholds are 37#137; the rate is 37#
127 &or ,6, and 137#197 &or *.,.
Case >atalit! rate
)ase &atalit/ is reported to !e 0.C7 0(o$pared 2ith 0.37 in -+rope
and 2.C7 &or the 1913#19 in<+ena pande$i(1. Fhe death rate
o& 0.C7 (o$pares to a rate o& 0.17 &or seasonal <+.
Fhe hi%hest death rate is in persons 50#"C /ears.
* ?e2 Oor5 )it/ telephone s+r9e/ &o+nd ,6, in 250,000 o& 3.3 $illion
people; (ase#&atalit/ rate 2as 0.00037. 00ew Kork City
Be"art%ent o- )ealth and 7ental )y$iene. ,realence o- fu&like
illness in 0ew Kork City! 7ay 2009. Aailable at!
htt"!##www.nyc.$o#ht%l#doh#downloads#"d-#cd#h1n18citywide8s
urey."d- Accessed Se"te%ber 1', 2009.1
Data !ased on (on:r$ed (ases are <a2ed !/ sele(ted +se o&
testin% that &a9ors serio+sl/ ill patients. 0Jarske ;, Ie$rand J,
Bonnelly CA, et al. Assessin$ the seerity o- the noel infuen.a
A#)101 "ande%ic. BMJ. 20092339!b2H40.1
0roKected cases and impact in the .nited 7tates
4n *+%+st 25, 2009, the PresidentDs )o+n(il o& *d9isors proGe(ted
that =1?1 $a/ in&e(t +p to hal& o& the U; pop+lation, 2ith
hospitaliation o& 1.3 $illion and lethal o+t(o$e in 30,000#
90,000.
Mortalit/: Media e$phasied the 90,000 :%+re; Fho$as .. 8rieden,
MD, MP=, Dire(tor o& the )D), e$phasied the 30,000 :%+re.
,$pa(t: Fhe PresidentDs )o+n(il o& *d9isors esti$ates that 507 o&
"0#120 $illion 2ill see5 $edi(al (are.
,)U !+rden o& =1?1 disease: Fhe *d9isor/ Panel to President
4!a$a proGe(ted that as $an/ as 300,000 patients (o+ld
reE+ire intensi9e (are and o((+p/ +p to hal& o& all ,)U !eds in
aMe(ted re%ions.
'#' ,e"ort on U$ Influenza A (H1N1) Infections
Fhe )D) has 1"00 people dedi(ated to the in<+ena eMort, a((ordin%
to )D) Dire(tor 8rieden. Fhe )D) (+rrentl/ esti$ates that there are
C3,000 in<+ena * 0=1?11 in&e(tions in the United ;tates and $ore
than "00 deaths. Fhe initial 9a((ine s+ppl/ o& 2.2 $illion doses o& the
nasal spra/, the li9e atten+ated 9ir+s 9a((ine, has started to arri9e.
Fhe )D) is e$phasiin% the sa&et/ o& the 9a((ine to (o+nter the
(a$pai%n that 9a((ines are har$&+l. /7c)u$h +, Cortuna +,
7cCarthy (. Swine fu $round .ero! a rare look into CBC. AFC 0ews.
6ctober 13, 2009. Aailable at! htt"!##abcnews.$o.co%#%#screen=
id?H77H094@"id?43H0'4A Accessed 6ctober 13, 2009.1
E8"erience in Ne. 7ealand +ith H1N1 Influenza
Fhis e'perien(e is 9al+a!le !e(a+se ?e2 Healand has %ood
s+r9eillan(e s/ste$s and is in the ;o+thern he$isphere, so the
(o+ntr/Ds 2inter <+ season 2ith si$+ltaneo+s seasonal <+ and
pande$i( =1?1 <+ is lar%el/ o9er. 0CBC. Sureillance -or the 2009
"ande%ic infuen.a A /)1011 irus and seasonal infuen.a iruses &&&
0ew Qealand, 2009. MM@. Mor! Mortal @5l/ .ep. 20092AH!91H&
921.1
7entinel L0 sur2eillance s!stem in Ne8 Mealand- De:nes ,6,
a(ti9it/ !ased on reports o& 9ol+nteer %eneral pra(titioners. .ates o&
50#2C9/100,000 pop+lation/2ee5 are (onsidered a9era%e &or nor$al
seasonal <+ a(ti9it/. .ates J C00/100,000 de:ne epide$i( le9els.
Fhe hi%hest rate 2as 23B (ons+ltations/100,000 pop+lation &or J+l/
13#19, 2009; this is 3 ti$es the pea5 rate o& 95/100,00 in 2003.
4irolo!- *nal/sis o& 52B in<+ena 9ir+s isolates in the sentinel
s+r9eillan(e la!s 052B strains1 and the nonsentinel la!s 03931
strains1 sho2ed that 2009 =1?1 in<+ena * a((o+nted &or a!o+t
"57 o& identi:ed strains.
0atients- Fhe ,6, rates 0e'pressed per 100,000 pop+lation1 in ran5
order: (hildren 1#C /ears 015C1; in&ants I 1 /ear 01101; 15#1B /ears
09B1; 20#3C /ears 09"1; 35#C9 /ears 0""1; 50#"C /ears 05B1; and P "5
/ears 0231.
Australia
6i5e ?e2 Healand, *+stralia represents a $odel o& 2hat $a/ o((+r in
the northern he$isphere !e(a+se it represents a so+thern
he$isphere (o+ntr/ 2ith %ood s+r9eillan(e and re(ent si$+ltaneo+s
epide$i(s o& 2009 =1?1 and seasonal <+. =i%hli%hts o& a re(ent
in<+ena report &ro$ this (o+ntr/:
)ase (o+nts: )on:r$ed (ases: 35,93" 0+nderreported1;
hospitalied: C"C9; deaths: 1"9 03."7 o& hospitalied patients,
Fa!le 91
,a"le 9- Infuenza +utcomes in 'ustralia
7e2ere Cases Hospitalized
Median a%e 0/rs1
)o$or!idit/
Pre%nan(/
31
"C7
a

C7
a
a
7 o& hospitalied patients
!
,)U patients: B57 reE+ired $e(hani(al
9entilation and 1C7 reE+ired -)M4.0Bwyer BE. 7ini Iecture.
,ande%ic infuen.a /)101109 actiity in Australia & i%"lications -or
the northern he%is"here. ,ro$ra% and abstracts o- the 49th
Interscience Con-erence on Anti%icrobial A$ents and Che%othera"y
/ICAAC12 Se"te%ber 12&1A, 20092 San Crancisco, Cali-ornia. Abstract
D&12'9a.1
,ss+e o& transplantation o& non#l+n% or%ans: sin%le (ase 2ith no
trans&er o& in&e(tion. Kire$ia is rare (o$pared 2ith in<+ena
d+e to =5?1, and a+topsies in 13 (ases sho2ed no
e'trap+l$onar/ in&e(ted sites.
Do$inant seasonal in<+ena strain that (o(ir(+lated 2as =3?2
in<+ena *, !+t 2009 =1?1 Ap+shed o+t seasonal in<+enaA;
2009 =1?1 a((o+nted &or B"7 o& ,6, patients in ,)Us.
,esource 3ist
*)=*. Pande$i( in<+ena s+r9eillan(e. in<+ena#li5e illness in
(olle%es and +ni9ersities. @ee5l/ )ase Data &or the period
4(to!er 1B#23, 2009. *9aila!le at:
http://222.a(ha.or%/,6,Xs+r9eillan(e.(&$ *((essed ?o9e$!er
10, 2009.
*+stralia and ?e2 Healand -'tra(orporeal Me$!rane 4'/%enation
0*?H -)M41 ,n<+ena ,n9esti%ators. -'tra(orporeal $e$!rane
o'/%enation &or 2009 in<+ena * 0=1?11 a(+te respirator/
distress s/ndro$e. J*M*. 2009 4(t 12. U-p+! ahead o& printV
Bartlett JG, Borio 6. =ealth(are epide$iolo%/: the (+rrent stat+s o&
plannin% &or pande$i( in<+ena and i$pli(ations &or health (are
plannin% in the United ;tates. )lin ,n&e(t Dis. 2003;C":919#925.
*!stra(t
)D). 2009#2010 in<+ena season 2ee5 C2 endin% 4(to!er 2C,
2009. 8l+Kie2. *9aila!le at: http://222.(d(.%o9/<+/2ee5l//
*((essed ?o9e$!er 1, 2009.
)D). 2009#2010 in<+ena season 2ee5 C1 endin% 4(to!er 1B,
2009. 8l+Kie2. 4(t 2C, 2009. *9aila!le at:
http://222.(d(.%o9/<+/2ee5l// *((essed 4(to!er 2B, 2009.
)D). Ba(terial (oin&e(tions in l+n% tiss+e spe(i$ens &ro$ &atal
(ases o& 2009 pande$i( in<+ena * 0=1?11 # U;, Ma/ # *+%+st
2009. MM@. Mor! Mortal @5l/ .ep. 2009;53:earl/ release.
)D). ,n&or$ation on =1?1 in<+ena and =1?1 9a((ination and
treat$ent &or (hildren. )lini(ian 4+trea(h and )o$$+ni(ation
*(ti9it/ )on&eren(e )all. 4(to!er 23, 2009.
)D). Beha9ioral .is5 8a(tor ;+r9eillan(e ;/ste$. *9aila!le at:
http://222.(d(.%o9/B.8;;/ *((essed 4(to!er 2B, 2009.
)D). =1?1 <+ 0s2ine <+1: %eneral in&or$ation. *9aila!le at:
http://222.(d(.%o9/h1n1<+/%eneralXin&o.ht$ *((essed
;epte$!er 1", 2009.
)D). =ospitalied patients 2ith no9el in<+ena * 0=1?11 9ir+s
in&e(tion ### )ali&ornia, *pril#Ma/. MM@. Mor! Mortal @5l/ .ep.
2009;53:53"#5C1. *!stra(t
)D). ,ntensi9e (are patients 2ith se9ere no9el in<+ena * 0=1?11
9ir+s in&e(tion ## Mi(hi%an, J+ne 2009. MM@. Mor! Mortal @5l/
.ep. 2009;53:BC9#B52. *!stra(t
)D). ,nteri$ %+idan(e &or (lini(ians on identi&/in% and (arin% &or
patients 2ith s2ine#ori%in in<+ena * 0=1?11 9ir+s in&e(tion.
J+ne 2009. *9aila!le at:
http://222.(d(.%o9/h1n1<+/identi&/in%patients.ht$ *((essed
;epte$!er 1", 2009.
)D). Le/ &a(ts a!o+t seasonal in<+ena 0<+1. *9aila!le at:
222.(d(.%o9/<+/5e/&a(ts.ht$ *((essed ;epte$!er 25, 2009.
)D). ?e+rolo%i(al (o$pli(ations asso(iated 2ith no9el in<+ena *
0=1?11 in&e(tion in (hildren ## Dallas, Fe'as, Ma/ 2009. MM@.
Mor! Mortal @5l/ .ep. 2009;53:BB3#BB3. *!stra(t
)D) 4nline ?e2sroo$. @ee5l/ 2009 =1?1 8l+ Media Brie:n%.
4(to!er 22, 2009. *9aila!le at:
http://222.(d(.%o9/$edia/trans(ripts/2009/t091023.ht$
*((essed 4(to!er 2", 2009.
)D) 4nline ?e2sroo$. @ee5l/ 2009 =1?1 8l+ Media Brie:n%.
4(to!er 9, 2009. *9aila!le at:
http://222.(d(.%o9/$edia/trans(ripts/2009/t091009.ht$
*((essed 4(to!er 22, 2009.
)D). Pne+$onia hospitaliations a$on% /o+n% (hildren !e&ore and
a&ter introd+(tion o& pne+$o(o((al (onG+%ate 9a((ine ### United
;tates, 199B#200". MM@. Mor! Mortal @5l/ .ep. 2009;53:1#C.
*!stra(t
)D) Press Brie:n% Frans(ripts. @ee5l/ 2009 =1?1 8l+ Media
Brie:n%. 4(to!er 1, 2009. *9aila!le at:
http://222.(d(.%o9/$edia/trans(ripts/2009/t091001.ht$
*((essed 4(to!er 22, 2009.
)D). ;+r9eillan(e &or the 2009 pande$i( in<+ena * 0=1?11 9ir+s
and seasonal in<+ena 9ir+ses ### ?e2 Healand, 2009. MM@.
Mor! Mortal @5l/ .ep. 2009;53:913#921. *!stra(t
)D). ;2ine#ori%in in<+ena * 0=1?11 9ir+s in&e(tions in a s(hool ##
?e2 Oor5 )it/, *pril 2009. MM@. Mor! Mortal @5l/ .ep
Dispat(h. 2009;53:1#3. *9aila!le at:
http://222.(d(.%o9/$$2r/pre9ie2/$$2rht$l/$$53d0C30a1.ht
$ *((essed ;epte$!er 25, 2009.
)D). Update: ,n<+ena a(ti9it/ Y United ;tates, *+%. 30#4(t. 31,
2009. MM@. Mor! Mortal @5l/ .ep. 2009;53:123"#12C1.
*!stra(t
)D). Update: ;2ine#ori%in in<+ena * 0=1?11 9ir+s ### United ;tates
and other (o+ntries. MM@. @5l/. 2009;53:C21.
)D). Use o& in<+ena * 0=1?11 2009 $ono9alent 9a((ine ###
re(o$$endations o& the *d9isor/ )o$$ittee on ,$$+niation
Pra(ti(es 0*),P1, 2009. MM@. Mor! Mortal @5l/ .ep.
2009;530..#101:1.
)D), ,n<+ena Di9ision. 8l+Kie2. *9aila!le at:
http://222.(d(.%o9/<+/2ee5l// *((essed ?o9e$!er 13, 2009.
)han M. ;2ine <+ spreadin% at D+n!elie9a!leD rate: @=4 (hie&.
LhaleeG Fi$es. *+%+st 29, 2009. *9aila!le at:
http://222.5haleeGti$es.(o$/displa/arti(le.aspZ
':leWdata/international/2009/*+%+st/internationalX*+%+st20BB.
'$l[ionWinternational\(olW *((essed ;epte$!er 25, 2009.
)hopra K, 8landers ;*. Does statin +se i$pro9e pne+$onia
o+t(o$esZ )hest. 2009;13":1331#1333.
)ohen J. ;2ine <+ o+t!rea5, da/ !/ da/. ;(ien(e,nsider. J+l/ 1B,
2009. *9aila!le at:
http://!lo%s.s(ien(e$a%.or%/s(ien(einsider/spe(ial/s2ine#<+#
ti$eline.ht$l *((essed ;epte$!er 1", 2009.
)o$$ittee on the 8+t+re o& -$er%en(/ )are in the United ;tates
=ealth ;/ste$, ,nstit+te o& Medi(ine. -$er%en(/ Medi(al
;er9i(es: *t the )rossroads. @ashin%ton, D): ?ational
*(ade$ies Press; 200B.
D2/er D-. Mini 6e(t+re. Pande$i( in<+ena 0=1?1109 a(ti9it/ in
*+stralia # i$pli(ations &or the northern he$isphere. Pro%ra$
and a!stra(ts o& the C9th ,nters(ien(e )on&eren(e on
*nti$i(ro!ial *%ents and )he$otherap/ 0,)**)1; ;epte$!er 12#
15, 2009; ;an 8ran(is(o, )ali&ornia. *!stra(t K#12"9a.
8edson D;. )on&rontin% the ne't in<+ena pande$i( 2ith anti#
in<a$$ator/ and i$$+no$od+lator/ a%ents: @h/ the/ are
needed and ho2 the/ $i%ht 2or5. ,n<+ena 4ther .espi Kir+ses.
2009;3:129#1C2. *!stra(t
8l+.%o9. People 2ith health (onditions. *9aila!le at:
http://pande$i(<+.%o9/indi9id+al&a$il//health(onditions/inde'.h
t$l *((essed 4(to!er 2", 2009.
8l+Kie2. President 4!a$a si%ns e$er%en(/ de(laration &or =1?1
<+. 4(to!er 2C, 2009. *9aila!le at:
http://222.<+.%o9/pro&essional/&ederal/h1n1e$er%en(/102C200
9.ht$l *((essed 4(to!er 2", 2009.
8o' M. Fests sho2 <+ spreads &ro$ s(hools. .e+ters. 4(to!er 21,
2009. *9aila!le at:
http://222.re+ters.(o$/arti(le/health?e2s/idU;F.-59L3;92009
1021 *((essed ?o9e$!er C, 2009.
Gars5e F, 6e%rand J, Donnell/ )*, et al. *ssessin% the se9erit/ o&
the no9el in<+ena */=1?1 pande$i(. BMJ. 2009;339:!23C0.
Garten .J, Da9is )F, .+ssell )*, et al. *nti%eni( and %eneti(
(hara(teristi(s o& s2ine#ori%in 2009 *0=1?11 in<+ena 9ir+ses
(ir(+latin% in h+$ans. ;(ien(e. 2009;325:19B#201. *!stra(t
=arto(ollis *, M(?eill DG Jr .*reas hit hard !/ <+ in sprin% see little
no2. ?e2 Oor5 Fi$es. 4(to!er 3, 2009; se(t *1.
Greenho+se ;. 6a(5 o& paid si(5 da/s $a/ 2orsen <+ pande$i(.
?e2 Oor5 Fi$es. ?o9e$!er 2, 2009. *9aila!le at:
http://222.n/ti$es.(o$/2009/11/03/!+siness/03si(5.ht$lZXrW1
*((essed ?o9e$!er 10, 2009.
=ar9ard 4pinion .esear(h Pro%ra$, =ar9ard ;(hool o& P+!li(
=ealth. B+siness Preparedness: ?o9el ,n<+ena * 0=1?11. J+l/
1"#*+%+st 12, 2009. *9aila!le at:
http://222.hsph.har9ard.ed+/ne2s/press#releases/2009#
releases/!+sinesses#pro!le$s#$aintainin%#operations#
si%ni:(ant#h1n1#<+#o+t!rea5.ht$l *((essed ;epte$!er 1",
2009.
,toh O, ;hin/a L, Liso M. ,n 9itro and in 9i9o (hara(teriation o& ne2
s2ine#ori%in =1?1 in<+ena 9ir+ses. ?at+re. 2009;C"0:1021#
1025. *!stra(t
Jain ;, La$i$oto 6, Bra$le/ *M, et al. =ospitalied patients 2ith
2009 =1?1 in<+ena in the United ;tates, *pril#J+ne, 2009. ?
-n%l J Med. 2009;3"1:935#9CC.
Ja$ieson DJ, =onein M*, .as$+ssen ;*, et al. =1?1 2009 in<+ena
9ir+s in&e(tion d+rin% pre%nan(/ in the U;*. 6an(et.
2009;3BC:C51#C53. *!stra(t
Lhan L, *rino J, =+ @, .aposo P, et al. ;pread o& a no9el in<+ena *
0=1?11 9ir+s 9ia %lo!al airline transportation. ? -n%l J Med.
2009;3"1:212#21C. *9aila!le at:
http://(ontent.neG$.or%/(%i/(ontent/&+ll/3"1/2/212 *((essed
;epte$!er 1", 2009.
L+$ar *, Har/(hans5i ., Pinto ., et al. )riti(all/ ill patients 2ith
2009 in<+ena *0=1?11 in&e(tion in )anada. J*M*. 2009 4(t 12.
U-p+! ahead o& printV
6o+ie JL, *(osta M, @inter L, Jean ), et al. 8a(tors asso(iated 2ith
death or hospitaliation d+e to pande$i( 2009 in<+ena
*0=1?11 in&e(tion in )ali&ornia J*M*. 2009;302:139"#1902.
Maher B, B+tler D. ;2ine <+: 4ne 5iller 9ir+s, three 5e/ E+estions.
?at+re. 2009;C"2:15C#15B. *!stra(t
Mari(i(h ;M, ?e+& J6, 6ote F-, et al. ?e+rolo%i( (o$pli(ations
asso(iation 2ith in<+ena * in (hildren d+rin% the 2003#200C
in<+ena season in =o+ston, Fe'as. Pediatri(s. 200C;11C:e"2"#
e"33. *!stra(t
M(Geer *, Green L*, Ple9neshi *, et al. *nti9iral therap/ and
o+t(o$es o& in<+ena reE+irin% hospitaliation in 4ntario,
)anada. )lin ,n&e(t Dis. 200B;C5:15"3#15B5. *!stra(t
M(=+%h ., 8ort+na ., M()arth/ L. ;2ine <+ %ro+nd ero: a rare
loo5 into )D). *B) ?e2s. 4(to!er 13, 2009. *9aila!le at:
http://a!(ne2s.%o.(o$/$/s(reenZidW3BB309C\pidWC330"C5
*((essed 4(to!er 13, 2009.1
Morens D;, Fa+!en!er%er JL, 8a+(i *;. Pro$inent role o& !a(terial
pne+$onia as a (a+se o& death in pande$i( in<+ena:
i$pli(ations &or pande$i( in<+ena preparedness J ,n&e(t Dis.
2003;193:9"2#9B0.
Morishi$a F, Fo%ashi F, Oo5ota ;, et al. -n(ephalitis and
en(ephalopath/ asso(iated 2ith an in<+ena epide$i( in Japan.
)lin ,n&e(t Dis. 2002;35:512#51B. *!stra(t
?e2 Oor5 )it/ Depart$ent o& =ealth and Mental =/%iene.
Pre9alen(e o& <+#li5e illness in ?e2 Oor5 )it/: Ma/ 2009.
*9aila!le at:
http://222.n/(.%o9/ht$l/doh/do2nloads/pd&/(d/h1n1X(it/2ideXs
+r9e/.pd& *((essed ;epte$!er 1", 2009.
?o9el ;2ine#4ri%in ,n<+ena * 0=1?11 Kir+s ,n9esti%ation Fea$;
Da2ood 8;, Jain ;, 8inelli 6, et al. -$er%en(e o& a no9el s2ine#
ori%in in<+ena * 0=1?11 9ir+s in h+$ans ? -n%l J Med.
2009;3"0:2"05#2"15.
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*!stra(t
Authors and #isclosures
Author(s)
;ohn 6< &artlett% *#
Pro&essor o& Medi(ine, Johns =op5ins Uni9ersit/ ;(hool o& Medi(ine, Balti$ore, Mar/land; Dire(tor, =,K )are Pro%ra$, Johns =op5ins
=ospital, Balti$ore, Mar/landDis(los+re: John G. Bartlett, MD, has dis(losed the &ollo2in% rele9ant :nan(ial relationships:;er9ed on the
poli(/ !oard &or: Johnson \ Johnson Phar$a(e+ti(al .esear(h and De9elop$ent, 6.6.).;er9ed as an ad9isor or (ons+ltant to: P:er ,n(;
Fi!ote(, ,n(. ;er9ed on the data sa&et/ $onitorin% !oard &or: Fi!ote(, ,n(..e(ei9ed honoraria &ro$: *!!ott 6a!oratories