Findings of the study suggest that public sector workers who have the provision of paid sick leaves were more likely to be compliant to recommendations (stay home when ill) as compared to private sector employees. Also, flu pandemics can be resolved more quickly when access to paid-sick leave reaches rates nearing those in the public sector. Addressing this gap may be an important target point to mitigate spread of pandemic flu and other disease outbreaks for organizations.

To date, the pandemic virus has been mostly stable, and not mutated away from the vaccine strain. However Professor Oxford commented on a mutation which has been detected a number of times, the mutation at position 222 (also known as 225). Some have speculated that this mutation indicates increasing severity of disease. WHO has stated that the mutation so far “does not appear to pose a major public health issue”. The Professor advises that while you can detect antigenic changes and conclude what they mean for vaccine efficacy, it is very hard to say anything about the biology of those changes. The change has been found in mild cases (as well as severe), and in some of the early cases identified in California.

A study which examines outbreaks of pandemic flu in long-term care facilities in three US states, published in January 29 edition of Morbidity and Mortality Weekly, was discussed. Professor found great variation in practices. In one facility no residents and no staff had been vaccinated against seasonal influenza compared to all residents and almost 70% of staff in another. The report recommends residents of such facilities should receive vaccination as should all health-care workers.

Professor Oxford’s briefing concluded with discussion of avian flu activity. Bird flu activity is increasing, as has been the pattern during previous northern hemisphere winters. An analysis of Egypt’s human cases of avian flu H5N1 in Eurosurveillance 28 January indicates the nation’s relatively low case fatality rate (27 of 90 cases) may be due to the speed of intervention. On average, cases that survived sought treatment within 2 days, whereas those that died took 6 days to do so.

Update February 5: The outbreak has been confirmed and officially reported to the World Organziation for Animal Health (OIE).

In the February 5 edition of Weekly Epidemiological Record, WHO summarizes the features of the 225 cases of Tamiflu-resistant  pandemic flu that have been detected globally since the start of the pandemic. More than 23,000 samples collected from 85 different countries have been tested for antiviral sensitivity, and all but 225 were sensitive to Tamiflu. No samples showed resistance to Relenza (zanamivir) has been found, including in all the Tamiflu-resistant strains.

About 40 percent of the Tamiflu-resistant strains were found in patients with extremely reduced immune systems. Most had flu infections that were treated with Tamiflu, and the virus may have become resistant within their bodies during treatment. Around 11 percent of the cases occurred in people who had not been given Tamiflu at all, and another 11 percent occurred in people who were taking the drug preventatively. Some of these cases occurred in clusters in hospitalized patients. In at least four cases, the drug-resistant virus was transmitted from person to person.

One other instance of person-to-person transmission of resistant flu is documented. A resistant virus strain passed among seven adults who traveled together via train between Ho Chi Minh City and Hanoi, Vietnam, in July 2009. None of them are known to have had underlying medical or immunocompromising conditions.

Pandemic Information Service Members - for more information log in to the H1N1: Antivirals page.

This week's update from WHO again reports generally low flu activity globally. Most areas in the temperate Northern Hemisphere experienced peak activity in October through November. Although a few countries in Europe recorded a slight rise in acute respiratory / influenza-like illness over the last 2 weeks (Slovakia, Belarus, and the Russian Federation), only 14 percent of samples were positive for flu (compared to 45 percent during the peak). Although activity is declining in East Asia, there is still widespread transmission. India overall has declining activity, and appears to have had peak activity in mid-December. Nevertheless, active transmission continues - particularly in the west.

In China, the pattern of flu appears to be different. Although levels have declined to seasonal norms, almost 1/3 of all samples tested are still positive for flu. The majority of flu is seasonal influenza type B (66 percent) while pandemic H1N1 is now only responsible for 34 percent of positive flu tests. To date, this is the only area where seasonal flu has become the more common strain. Since the emergence of the pandemic H1N1 2009 strain, that virus has virtually "pushed out" the seasonal strains in other areas.

North Africa reached peak activity in late December / early January and now has declining - but still widespread - flu transmission. In the temperate Southern Hemisphere, pandemic H1N1 continues to be detected without causing sustained outbreaks.

A study published in the online journal Eurosurveillance pooled and analyzed data on weekly mortality due to all causes from eight European countries (including one region): Belgium, Denmark, Greece, Hesse (region of Germany), Malta, Netherlands, Sweden and Switzerland, taking into account a total population of 66.8 million people.

Researchers compared the excess numbers of deaths observed in a period from July 5 to 20 December 2009 (corresponding to Epidemiological weeks 27 to 51) with those in the corresponding periods in previous three years: 2006, 2007 and 2008.

Results showed that there was a steep increase in excess mortality in the 5-14 years and 0-4 year age groups in the period from October to December 2009. This period coincided with widespread pandemic influenza activity in these nations. An excess of 77 deaths were recorded in the 5-14 years age group which roughly corresponded to a 28 per cent increase. The study also found that there was no major excess of deaths in adults for the same period.

This study is important from the view in that it makes it possible to compare mortality from seasonal flu with pandemic flu. Earlier, the WHO had reported that it was misleading to compare severity of pandemic flu to seasonal flu by comparing the respective number of deaths.

Update 5 February: Tests by the UK laboratory have confirmed highly pathogenic avian influenza H5N1. Results have been reported to the World Organization for Animal Health (OIE).

Update 2 February: In the last week of January another 300 chickens died suddenly in West Java.  Rapid tests conducted on the chickens indicated that they were infected with the H5N1 influenza virus.  A woman confirmed to have been infected with the avian influenza virus died in East Jakarta in late January.

An outbreak of avian influenza H5N1 has been reported at a commercial poultry farm in the Joypurhat district of Bangladesh. The district is in northern Bangladesh, in the Rajshahi division. Around 250 birds died, and the remaining 900 or so birds in the flock were culled. The cause of infection is not yet known, and authorities are investigating the situation further. View the OIE report. Bangladesh last officially reported an outbreak among its poultry in September 2009, on a commercial farm in southern Bangladesh. (posted January 21)

Update February 1: A second farm in Joypurhat district reported cases among its poultry, as did a farm in the Sirajgonj district. Both are located in the Rajshahi division in northwestern Bangladesh.

A few other illnesses are gaining traction in some places. Influenza B activity is increasing in China. Seasonal H3N2 and type B viruses are circulating at low levels in parts of Africa, and east and Southeast Asia. In some countries in the Americas, there have been increased cases of RSV (respiratory syncytial virus). These may be responsible for slight increases in influenza-like activity reported from those nations. Nevertheless, pandemic H1N1 flu remains the predominant virus circulating worldwide.

More H5N1 bird flu outbreaks have been reported in Dien Bien province, where birds were sick in November and a person was killed by the virus in December. The new outbreaks struck one farm each in the Thanh Hung and Thanh Yen districts. In all, about 800 birds died of the disease and the rest of the 500 or so birds in the flocks were culled. Government officials have issued strict warnings on the disposal of dead birds and have also banned the slaughter, transportation, trading and use of sick or unhealthy birds in these two communities. Authorities have also tightened the control regarding poultry breeding in and around the communities as well as the provincial capital, Dien Bien Phu.

An outbreak was also reported among birds on a farm in Soc Trang. Around 350 birds in a flock of 500 died of the virus, and the rest were culled. Soc Trang is in southern Vietnam in the Mekong Delta.

The other two new cases were children, like many of Egypt's bird flu patients. Both were hospitalized, treated and released. One was a 1-year-old baby from the Dakahlia governorate. The other was a 3-year-old child from the Asyut governorate. The child may have contracted the virus from relatives, in a rare case of human-to-human transmission. Relatives interacted with poultry and then with the child. There are no reports that the relatives themselves are sick.  (posted January 27)

Update January 28: Human-to-human transmission is no longer suspected in the Asyut case. In a posting on their website, the World Health Organization said all the cases in Egypt appear to have had contact with infected birds - which is by far the most common way for a person to contract avian flu H5N1.

An article in the Journal of Infectious Diseases examines how useful masks and hand hygiene measures were to help contain the spread of influenza-like illnesses (ILI). The study involved three groups of students living in university residence halls. One of the groups practiced hand hygiene by using hand sanitizing gel and wore face masks within the hall as much as possible. The second group used masks without hand hygiene measures, and the third (control) group used no particular interventions. At the end of a six week observation period, there was a reduced rate of ILI among the students using both masks and hand hygiene (between 35-51 percent). Students in the mask-only group also showed reduced illness, though it was not statistically significant. This study was performed in 2006-2007, before pandemic H1N1 emerged, and thus only looked at seasonal (not pandemic) flu. However, the findings are likely applicable to all types of influenza.

The Brazilian Health Ministry announced its national strategy against an anticipated second wave of pandemic flu. The government is planning a nationwide vaccination campaign to reduce the number of severe cases and deaths, and to decrease burden on healthcare facilities. They aim to immunize around 62 million people before the onset of their winter flu season, which begins in June. Vaccinations will begin in early March for healthcare workers and people in indigenous groups. Other priority groups, as based on WHO recommendations, will be vaccinated from March 22 on. In addition to WHO defined groups, officials will also target children aged six months to two years and adults 20-29 years of age. These two groups had the highest proportion of severe illness during Brazil's first pandemic wave, according to their collected data.

In other preparatory moves, the government doubling the number of pandemic flu diagnosing laboratories from 7 to 14 and increasing its stockpile of antiviral drugs. New rules will be enforced regarding Tamiflu, which will be available on prescription only. It will be provided free of cost at gas stations, public hospitals and 560 units of the People's Pharmacy program and at subsidized rates in other related pharmacies. The government is also investing effort and resources in publicizing the vaccination campaign, equipping ICUs and training medical staff.

Posted January 22: There is an outbreak of avian influenza in the Thach Quy ward of Ha Tinh province, in central Vietnam. The affected flock contains around 550 ducks, nearly 400 of which died. Tests confirmed avian influenza H5N1. Officials destroyed the remaining ducks and imposed measures to prevent the disease from spreading further. Avian flu typically increases seasonally in Vietnam during the winter months, and outbreaks have recently been reported in poultry in several northern provinces.

The World Health Organization (WHO) released a statement regarding allegations of conflict of interest and 'fake' pandemic. This statement builds further on their January 14 press conference, led by Special Advisor to the Director General on Pandemic Influenza Dr. Keiji Fukuda (see Flu News Article below from 15 January). The statement reiterated that WHO's pandemic polices and responses were not improperly influenced by the pharmaceutical industry. Also, allegations of a 'fake' pandemic to bring monetary benefits to the industry were strongly disputed. They stated the allegations were scientifically wrong and historically incorrect. Their factual response included:

• Lab analyses showed that pandemic H1N1 was very different to other flu virus circulating among people.
• Epidemiological evidence proved human-to-human transmission.
• Pandemic H1N1 flu can cause severe disease and death.
• The virus imposed a heavy burden on intensive care units, and a very severe form of primary viral pneumonia occurred in some cases. 
• The virus had rapid geographic spread.

WHO stated that "the world is going through a real pandemic" and their committee would welcome any legitimate review process that could improve their work.

Efficacy of rapid tests: Speaking about a study recently published in JAMA, Professor Oxford highlighted the limited usefulness of rapid tests in detecting pandemic flu. In this study, fewer than half of the patients who actually had flu were found positive when given a rapid test. This shows that a "negative" rapid test does not mean a patient is free from flu infection. Diagnosis and treatment should depend on their symptoms and situation more than these rapid tests. When people test positive for flu on a rapid test, it is more likely to be an accurate result.

Areas for improvement: The Professor discussed an article published in The Journal of Emerging Infectious Diseases which highlighted the mammalian origins of pandemic H1N1 flu. Researchers found that the virus may have initially emerged 17 years ago, in animals. Professor Oxford said that, ideally, new animal viruses should be detected sooner to help protect human health. He pointed to the need for increased and improved collaboration in the spheres of veterinary and other health sciences. He also highlighted another article which discussed the fact that health services in some areas were stretched beyond capacity even by this moderate pandemic. This points up a need to reinforce those systems to prepare for other, more severe disease outbreaks.

WHO will soon evaluate vaccine composition: Professor Oxford reminded listeners that WHO will have its biannual vaccine meeting in February 2010. They will look at data collected worldwide to see if any "new" or different versions of influenza are circulating. He believes they will find at least one, since flu viruses are highly changeable by nature. The question will then be whether the strain is significantly different enough to spark a reformulation of vaccines, or if existing vaccines will be expected to continue to provide protection.

The Centre for Health Protection (CHP) set up a surveillance system when it launched its pandemic vaccination campaign. The system logs adverse events (side effects) following immunization. The CHP investigates the events on a case-by-case basis to determine whether there is any causal association between the vaccine and the reported side-effect.

The CHP investigated a case of intrauterine death in a 37-year-old pregnant woman who had been vaccinated. She also had an underlying condition for which she was taking medication. In their press release about the situation, the CHP says she was vaccinated in late December. Fetal death was confirmed about 20 days later. Authorities have not found any evidence linking the incident to her vaccination. The CHP report states, "According to the World Health Organization, studies to date do not show harmful effects from the H1N1 vaccine with respect to pregnancy or a developing embryo or foetus.” Pregnant women are at high-risk for developing complications - sometimes fatal - if they contract influenza. They make up a disproportionately large number of the people who have died from pandemic H1N1. Public health authorities worldwide generally agree that the benefits of immunization far outweigh any risks, none of which have been documented.

A study by experts and scientist from the United Kingdom’s Health Protection Agency (HPA) has found that one in every three children from England’s most affected areas caught influenza H1N1 during the first pandemic wave. These findings were 10 times greater than those initially estimated from clinical surveillance data. The study, published in The Lancet, also showed that children have an important role in the transmission of influenza because they are at greater risk of infection. Children were identified as a key target group for vaccination for their own protection, and for the protection of the community. 

These findings support the recommendations of the World Health Organization, indicating that pork harvested from infected pigs will not infect humans with the virus - provided that basic food safety and hygiene practices are followed (which are important when cooking any pork product). View the study in PLoS ONE.

Update January 20: Norway cancelled about 30 percent of its vaccine order after a mutual agreement with the supplier company.

The US Centers for Disease Control and Prevention have released an updated estimate about how many residents were infected with pandemic flu. At the midrange of the estimate scale, they say around 55 million people in the US had the disease, with more than 11,000 cases proving fatal. This is up from the estimated 47 million cases/9,800 deaths reported in a December update.   

The pandemic vaccine, which was in short supply when the nation's demand (and case count) surged in October and November 2009, is now widely available. However, public interest has waned. A separate CDC report said only one in five Americans have been vaccinated, and nearly all (90%) of those adults considered at risk for complications/severe infections remain unvaccinated. There could be additional pandemic waves - possibly with a mutated virus - in the US and elsewhere, so officials are strongly urging people to get the vaccine.

He said unequivocally that this is a real pandemic, as it met the defining criteria in terms of type of disease, spread and human susceptibility. He added that the WHO definition of a pandemic - which was created more than 10 years ago - was not changed to suit the 2009 situation, merely updated, and that the core tenant remained the same: a pandemic is worldwide disease outbreak. WHO has historically, and intentionally, avoided discussing a disease's severity in its definition of a pandemic (since the severity can vary greatly depending on the causative agent of the pandemic). He also addressed severity in terms of whether WHO "overplayed" the pandemic, saying the strategy was to prepare for the worst and hope for the best - which is a valid and traditional way for health officials to proceed in times of uncertainly, such as when faced with an emerging disease.

WHO will conduct an evaluation of its response and policies, as called for by the International Health Regulations. Dr. Fukuda reminded people that the pandemic is still underway, and said that calling the pandemic fake is "wrong and irresponsible" as well as disrespectful to those who fell seriously ill or died.

This is the first time avian flu has been reported among Indian poultry since May 2009.

The second outbreak occurred in the Pademawu Village, Sub Pademawu, Pamekasan, East Java. Around 100 chickens died and are said to have been positive for bird flu using rapid tests. Local authorities reportedly buried the dead poultry, disinfected the area and distributed H5N1 vaccine to local birds.

H1N1 survival of the fittest - Professor Oxford reviewed various H1N1 surveillance reports including reports from the World Health Organization (WHO) and the European Centers for Disease Control and Prevention (ECDC). Prof. Oxford said monitoring flu surveillance around the world will give a good indication of the types of flu virus circulating, and current evidence that H1N1 remains the dominant strain. It is 'crowding out' other seasonal influenza strains. For example, the ECDC reported over 99% of the viruses detected are the pandemic H1N1 strain.

H1N1 and comments on the over 65 population - There is a generally accepted idea that people over 65 years old may have some level of immunity against pandemic H1N1. Professor Oxford continues to support this idea. He also pointed out that when people in this age group are infected with pandemic H1N1, they may have a more severe infection or be more likely to develop complications than younger age groups. Information from the United Kingdom indicated that around a quarter of all those admitted to Intensive Care Units (ICU) were individuals from the over 65 age group. He says it will be 'wise' for the over 65 population to get vaccinated against pandemic H1N1 flu. Even though various media sources report the pandemic virus is 'mild', many people have died from this pandemic. Even the Chief Medical Officer from the United Kingdom, Sir Liam Donaldson, was quoted as saying: "We are in the 21st century. People do not have to die from vaccine preventable illnesses."

H1N1 vaccine manufacturers commended - Although some governments have purchased an oversupply of H1N1 vaccines and are canceling/donating their excess vaccine stockpiles, Prof. Oxford commended governments on their pandemic preparedness efforts. He highlighted that vaccine manufacturers deserve a special commendation for fast turnaround time regarding the efforts involved to research, develop and manufacture the pandemic vaccine for society.

Study regarding short term school closures - Professor Oxford discussed a study conducted by the University of Pittsburgh. The authors which looked at mathematical modeling of school closures based on United States census data. The study found that schools may need to be closed for at least eight weeks to cause a significant decrease to reduce pandemic influenza transmission. The new evidence suggests duration of school closures may have a better outcome at reducing spread - rather than (or in addition to) shutting down schools as soon as a pandemic strikes. The paper is published in the Journal of Public Health Management and Practice.

The Medical Journal of Australia published a case study of the country's first known Tamiflu-resistant case of pandemic flu, which occurred in September of 2009. The young adult man was immunosuppressed following a kidney transplant. He initially had a routine pandemic infection which was treated with Tamiflu for 10 days. Several days after treatment ended, he again developed flu symptoms. Test result showed he now had a Tamiflu-resistant strain of pandemic flu. Thus Tamiflu resistance appears to have developed within the patient's body, which is more common among immunosuppressed patients than other people.

Thousands of chickens have died in South Kalimantan, Borneo since the beginning of December. Presumably, all had avian flu H5N1, as samples collected from some of the animals were positive for the virus. More than 6,500 birds died across seven sub-districts, but no new human cases were reported. However, Indonesia does not report human cases in a timely manner, and sometimes delays information for several months.

Avian flu H5N1 has been found in almost every Indonesian province in the past few years. It is considered endemic (consistently present) among birds on the islands of Java, Sumatra, Sulawesi, and probably Bali. Sporadic outbreaks occur on other islands as well. When poultry are sick, the risk of human cases increases.

Like some other nations, France ordered more doses of pandemic H1N1 flu vaccine than it needed. Officials there anticipated that people would require two doses for protection, and purchased 94 million doses for its approximately 62 million residents. Ultimately, just one dose proved sufficient for protection. There was also less demand than anticipated - a trend that also echoes the experience of other European nations. Thus France and other overstocked nations like Germany and the Netherlands are willing to sell some excess vaccine supplies. French officials have fielded purchase requests from Egypt, Mexico, Qatar and Ukraine, according to media sources. Some nations may also donate excess vaccines to countries in need.

Evolution of the virus: As anticipated, the pandemic H1N1 virus continues to be the dominant flu A virus circulating in areas with flu activity. Seasonal type A influenzas (H3N2 and the seasonal version of H1N1) have been largely replaced by the pandemic strain so far, but seasonal B type influenzas are circulating. Thus it remains important for people to be protected by vaccination against both seasonal and pandemic flu. Professor Oxford also discussed the 'biological imperative': as more people become immune to the pandemic virus (either by past infection or via vaccination), the pandemic H1N1 virus might mutate to keep itself in circulation. One act of self-preservation might be to adapt to infect people over 65, a group that appears to have some pre-existing immunity to the pandemic virus in its current form. Thus far, the virus has ha da high fatality rate among the relatively few older adults who have been infected.

Being 'lucky' so far is no justification for complacency: The Professor quoted an article published in the British Medical Jourrnal by England's chief health official, Liam Donaldson: "A lower population impact than previous pandemics is not a justification for public health inaction." The chief stressed the importance of preventative steps (like vaccination and early antiviral treatment) even as the pandemic appeared to be slowing in some nations. Indeed, the World Health Organization said it is too early to declare the pandemic over. It could still cause additional waves even in North American and European countries that have passed their current peaks, and will circulate in the Southern Hemisphere once their flu season begins.  

New England Journal of Medicine publishes three interesting articles: Professor Oxford reviewed several articles he found particularly interesting in recent publication. One of them details the hospitalizations and deaths among children in Argentina, particularly babies under one year old. The Professor noted that children with slightly impaired immune systems - from HIV infection or cancer treatments, for example - were less likely to be hospitalized than children with fully functional immune systems. This could be related to the "cytokine storm", the idea that a healthy person's robust immune system may overreact when fighting severe flu. The overreaction may be counterproductive, and contribute to the illness. People with weaker immune systems would be less likely to have such a 'storm'. Professor Oxford poitned this out as interesting but not at all conclusive - and he plans to keep an eye out for more information in further research.

Another interesting study which looked at the issue of flu among pregnant women brought up this alarming fact: nearly 40 percent of these women showed false negative results when tested for pandemic flu using a rapid test. Further testing later showed they did in fact have pandemic H1N1. Professor Oxford used this opportunity to highlight the unreliability of rapid pandemic tests, which is widely recognized by health agencies but not necessarily by patients and laypeople.

Update January 4: The bird was confirmed to be H5N1 positive after a series of laboratory tests.

Last week, Chinese officials issued advice for women of childbearing age and those with young children to help protect them from infection. About 14% of China's recorded deaths occurred among pregnant women. Authorities advised women to consider delaying pregnancy until the outbreak risk drops. Pregnant women and those who have recently given birth are eligible for free pandemic vaccination.

This is the first time Indonesia has reported any human infections in over a year. Yet despite official silence, the international community strongly believed that humans were consistently contracting the virus in Indonesia. Human cases have been ongoing there for the past several years. In June 2008, Indonesia adopted a policy of only reporting human cases in aggregate numbers instead of reporting each case as it occurred. (This policy was poorly received by other nations, as it impedes research and increases risk to human health worldwide. The International Health Regulations require countries to report certain disease outbreaks/public health events - such as human cases of avian flu H5N1 - to the WHO within 24 hours.)

The World Health Organization (WHO) has updated its list of cumulative confirmed cases of H5N1. In all, Indonesia has reported 161 human cases, of which 134 were fatal.

Data from other regions is less robust. The limited information available from Africa shows active, high-intensity flu outbreaks in Northern African nations on the Mediterranean coast (Algeria, Tunisia, and Egypt). South Asian countries continue to see intense outbreaks. Flu activity remains active in some parts of central and west Asia, though some countries may have passed their peak.

All three recovered from their presumed second infection. Two were re-treated successfully with oseltamivir. The third, a 14-year old girl, was treated with amantadine since doctors initially diagnosed her with seasonal flu. (Amantadine is not considered effective against pandemic flu.) The authors conclude that the three patients were re-infected because there was a high rate of community infection and they did not develop complete immunologic protection within the period of re-exposure. The US CDC says it is unlikely - but possible - for people to be infected twice with the same flu virus. People with weakened immune systems are the most likely to be re-infected, since they may not develop full immunity during their first infection. A few probable cases of re-infection have been reported in the US and South Korea.

Dr. Margaret Chan, Director-General of the WHO, told the media that it is too early to say that the pandemic has peaked worldwide. Though some countries in the Northern Hemisphere have passed their pandemic peaks, other countries are yet to experience peaks. Since outbreaks continue and 'flu season' spans several more months in affected countries, it is likely that an accurate picture of the pandemic’s impact on the world will not emerge for several more months or even a year. The virus will continue to circulate, probably for at least another year, and may still mutate.

Dr. Chan also reminded people that, before pandemic flu H1N1 emerged, most scientists expected that the next pandemic would be caused by avian flu H5N1. So far, avian flu has killed around 60 percent of all humans infected. Though the current pandemic flu H1N1 has given all countries an opportunity to improve their flu response systems, the world is still not ready to deal with an avian flu pandemic. We still use "old" (egg based) vaccine production methods and have production capacity that is much too small to handle the increased demands a pandemic brings with it. Listen to the audio recording.

Avian flu H9N2 was first detected in humans in 1998, in five people in China. Since then a few more cases have been detected in people in Hong Kong. (Pandemic Information Service Members: for further information log in to the International SOS Avian Flu website and see the page Non-H5N1 Human Flu).

First, the numbers of deaths caused each year by seasonal influenza are estimates calculated using mathematical models. The figures given for pandemic flu deaths are confirmed fatalities. Moreover, the number of confirmed fatalities is unquestionably lower than the number of people who actually died from pandemic flu. Many countries - in accordance with WHO suggestions, and/or due to resource issues - stopped testing people for the virus once it was well-established in the community. Additionally, when people with pre-existing conditions get flu and die, their deaths are often attributed to the pre-existing condition instead of pandemic flu.

Second, counting flu deaths does not reflect the unusual age group affected most heavily by pandemic flu. Seasonal flus usually hit the elderly hardest. However, pandemic H1N1 has caused more infections, hospitalizations and deaths among younger people.

In its ongoing effort to describe and understand the pandemic, WHO currently labels the overall impact "moderate". A clearer picture is likely to emerge one to two years after the pandemic has peaked.

Update Dec 22: Around 20 percent of the volunteers vaccinated so far (5/24) have developed "cold-like" symptoms, according to media reports. This is not surprising. Symptoms such a runny or stuffy nose, sore throat, cough and tiredness are known side effects of nasal spray vaccines being used in the US and elsewhere.

• Expected impact: The number of firms expecting employee illness to have a negative impact on business has increased since May 2009.
• Workplace planning: The number of companies which had implemented contingency plans or were in the process of doing so had gone up. Limiting workplace risk continued to be the top priority. However, there was lack of communication in around 30 percent of companies, where employees received little information on emergency preparedness plans from Human Resources (HR).
• Measures enacted: Most companies were implementing measures (such as ensuring availability of hand sanitizers, frequently disinfecting common areas, educating employees on prevention measures and so on) to check the spread of pandemic flu.
• Leave policies: Most companies did not plan to modify their paid leave policies during the current flu season. Those that did change leave policies took actions like implementing a relaxed leave policy for employees in defined high-risk groups and creating sick leave/paid time off (PTO) donation programs.

Experts at the US Centers for Disease Control and Prevention (CDC) will continue to recommend two vaccine doses for children. In an editorial accompanying the study, the CDC pointed out that the study used twice the dosage used in US vaccines, which administer just 7.5 mcg to babies six to thirty-five months old. In addition, they said it was premature to assume that one dose would be sufficient to protect all young children. The study did not account for children with chronic health conditions or compromised immunity, and it only tested one vaccine product. The study and editorial were published online on December 21 by the Journal of the American Medical Association (abstracts of  the article and the editorial).