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  • #31
    Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

    EuroFlu - Weekly Electronic Bulletin Week 44 : 26/10/2009-01/11/2009 (edited)
    EuroFlu - Weekly Electronic Bulletin Week 44 : 26/10/2009-01/11/2009

    06 November 2009, Issue N 330 - Ukraine hit by pandemic, as influenza activity continues to rise in most countries in the WHO European Region


    Key points: week 44/2009
    • This report is based on material received from 40 of the 53 Member States in the WHO European Region and includes an overview of the situation in Ukraine.
    • On average, 45% of specimens collected from sentinel sources in the Region were positive for influenza virus.
    • The incidence of clinical respiratory illness has increased in 17 countries over the past three weeks, and for seven of these the proportion of sentinel specimens testing positive for influenza this week was 20% or greater.
    • Pandemic (H1N1) 2009 was dominant in 28 countries and accounted for 99% of influenza A virus subtype detections.
    • From 27 October to 4 November, 11 countries reported a total of 47 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection. Nevertheless, the majority of pandemic cases have resolved without complications.


    Ukraine

    On Monday, 2 November, a team of nine experts from WHO, the European Centre for Disease Prevention and Control (ECDC), and the United Nations Childrens Fund (UNICEF) arrived in Ukraine to investigate high levels of acute respiratory illness (ARI). The team was dispatched at the request of the Ministry of Health of Ukraine. The experts were briefed in Kyiv before heading to the western city of Lviv and other affected areas.

    Preliminary reports indicate that the rapidly evolving situation in the country is mainly related to pandemic (H1N1) 2009 influenza. The results received from the examination of samples submitted earlier by national laboratories in Kyiv to the WHO collaborating centre for reference and research on influenza in London, United Kingdom, continue to confirm cases of pandemic (H1N1) 2009 virus infection. At this stage, however, other causes for clusters of respiratory illnesses cannot be ruled out.

    On 4 November, the Minister of Health of Ukraine reported 70 deaths, 235 patients in a critical condition and more than 250 000 cases of influenza-like illness (ILI). Lviv is one of the most affected regions, with more than 100 000 people reportedly sick with ILI. WHO/Europe regularly issues updated information on the situation in Ukraine on its web site.


    Current situation: week 44/2009

    17 countries have reported increases in ILI and/or ARI consultations (defined as countries with increases in the previous three weeks). These increases have been particularly notable in the group aged 514 years. In 7 of these countries (Belgium, Germany, the Netherlands, Norway, Spain, Sweden and the United Kingdom (Northern Ireland)), the positivity rate of sentinel swab specimens exceeded 20% (minimum number of tested sentinel specimens: 20). In Norway, ILI consultation rates are above the maximum rates recorded in four previous seasons. To lessen the burden on physicians and improve the accessibility of antiviral drugs (oseltamivir and zanamivir), the Norwegian Government has made them available as over-the-counter medications (see press release in Norwegian).

    The intensity of clinical activity was described as very high in Iceland and Ireland for the second week in a row, and in the Russian Federation (Urals region) for the first time. Eight countries described high clinical activity: Belarus, Bulgaria, the Netherlands, Norway, Italy, Russian Federation (far eastern, Siberian, north-western and central regions), Sweden and the United Kingdom (Northern Ireland). The clinical incidence of ILI and/or ARI was reported as widespread in 11 countries: Belgium, Iceland, Ireland, Israel, Italy, the Netherlands, Norway, the Russian Federation, Spain, Sweden and most of the United Kingdom (England, Wales, Northern Ireland).

    Ukraine reported medium intensity, regional clinical incidence and severe impact of influenza on health services.

    Impact was reported moderate in 7 countries and low in 16 others. For an overview, see the Seasons tables section on EuroFlu.

    While clinical influenza activity has increased over the past weeks in 17 countries, it may have passed its peak in Ireland, Iceland and the United Kingdom (Northern Ireland). Countries with recent increases in influenza activity include Bulgaria, Norway and the Russian Federation, indicating the further circulating of influenza across the European Region. In week 44/2009, levels of clinical influenza activity above the baseline were observed in Portugal, Serbia and Ukraine, and the level in Ukraine was significantly higher than those in the same week in six previous seasons.

    In the period 27 October 4 November, 11 countries reported 47 new deaths associated with laboratory-confirmed pandemic (H1N1) 2009 influenza: Belgium (2), Bulgaria (1), Croatia (1), Germany (3), Ireland (8), Norway (4), Portugal (2), the Republic of Moldova (1), Turkey (8), Ukraine (1) and the United Kingdom (16). This raises the total number of deaths reported since April 2009 from 281 to 328.

    Croatia and Ukraine reported their first laboratory-confirmed deaths during this week.


    Virological update: week 44/2009

    Of the 19 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 0% (Azerbaijan, Georgia) to 85% (United Kingdom (Northern Ireland)). Sentinel physicians in the Region collected 2730 respiratory specimens in week 44/2009, of which 1219 (45%) were positive for influenza virus. This is a much higher proportion than is typical for week 44 (less than 4% during 20042008). Of the 1219 influenza virus detections, 1218 were type A (1156 pandemic A(H1), 1 A(H3) and 61 not subtyped) and 1 was type B.

    In addition, 7333 non-sentinel-source specimens were reported positive for influenza virus in week 44/2009: 7328 type A (5572 pandemic A(H1), 36 A(H3), 31 seasonal A(H1), 1689 not subtyped) and 5 type B. The seasonal influenza A subtype detections were reported by Kazakhstan and the Russian Federation.

    Since week 40/2009, 21 851 specimens have tested positive for influenza virus. Of these, 17 644 (81%) were pandemic influenza A(H1), which accounts for 98% of all influenza A viruses that were subtyped. In addition, 335 were seasonal influenza A/H1; 87 were influenza A(H3); 3726 were influenza A not subtyped; and 59 were influenza B. Since week 40/2009, the number of influenza detections has risen sharply, from about 1600 to more than 8500 in week 44/2009. Three countries (Norway, the Russian Federation and Spain) accounted for more than 4000 of these detections. This number far exceeds the peak of detections during the summer of 2009 (about 3000 in week 30/2009) and is the highest recorded number of positive specimens in the Region in any week since 1996 (see graphs for Europe).


    Comment

    Qualitative reporting, clinical trend data and virological data are all consistent with an increasing intensity and geographic spread of influenza infections in the European Region. For the first time, countries in the Region reported very high intensity of clinical influenza activity. Influenza detections far exceed historical peaks and indicate a surge on the laboratories in several countries. The pandemic (H1N1) 2009 virus is dominant in most countries and continues to account for high levels of influenza activity for the time of year. Since the start of the pandemic, Ukraine is the first country to report a severe impact, mainly reflecting the strain on hospital and intensive care services. This situation highlights the need for countries to be prepared to cope with a surge of patients with severe respiratory disease, to identify best-practice scenarios for treatment and to implement vaccination programmes.


    Further information

    The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.
    (...)

    Network comments (where available)
    • Croatia
      • 1 case of death presenting as pneumonia (SARI) with confimed A/H1N12009 infection. This is the first new influenza associated death in Croatia Note: case included in ILI figures
    • Italy
      • During this last week, a significant increase in the H1N1v influenza lab-confirmed cases has been reported, if compared to the previous week.
    • Norway
      • The number of virus detections has continued to rise and are now very high, as is the positivity rate for all laboratories. The positivity rate in sentinel specimens is also high, but there was a decline since the previous week. The positivity rate is higher in the southeast and southwest, and lower in the north. It is also higher in densely populated areas than in many countryside communities. The decline in sentinel positivity rate seems to reflect more active sampling in areas that are lagging behind in the unfolding of the epidemic.
    • Portugal
      • Incidence rate is increasing but sligthly above the basezone.
    • Slovenia
      • Among non-sentinel 6 specimens were from hospitals, in 5 of them Influenza type A, subtype pH1 was confirmed. One of hospitalized patients died. This is the first fatal case in Slovenia.
    • Switzerland
      • In Switzerland, only data on hospitalisations for laboratory-confirmed pandemic (H1N1) 2009 cases are currently available: for these figures, the denominator is the whole population.

    (...)
    -

    <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

    Comment


    • #32
      Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

      EuroFlu - Weekly Electronic Bulletin - Week 45 : 02/11/2009-08/11/2009 - 13 November 2009, Issue N 331 (edited)
      EuroFlu - Weekly Electronic Bulletin - Week 45 : 02/11/2009-08/11/2009 - 13 November 2009, Issue N 331

      Further increase in detections of pandemic (H1N1) 2009 in the WHO European Region. Seven countries report very high influenza activity


      Key points: week 45/2009
      • This report is based on material received from 43 of the 53 Member States in the WHO European Region and includes an update of the situation in Ukraine.
      • On average, 45% of specimens collected from sentinel sources in the Region tested positive for influenza virus.
      • The incidence of clinical respiratory illness has increased in 17 countries over the past three weeks, and for eight of these the proportion of sentinel specimens testing positive for influenza this week was 20% or greater.
      • Notably, countries in Scandinavia, eastern Europe and south-eastern Europe reported high or very high intensity of influenza.
      • Pandemic (H1N1) 2009 was dominant in 36 countries and accounted for 99.7% of influenza A virus subtype detections.
      • Most influenza pandemic cases have resolved without complications. From 5 to 12 November, 18 countries reported a total of 145 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection.


      Ukraine

      There have been 174 deaths due to acute respiratory infection (ARI) reported from Ukraine and 344 people are currently in intensive care units, 45 of whom are on mechanical ventilation. Rates of ARI are at a higher level than any reported for six years and in some regions for 13 years.


      Current situation: week 45/2009

      Seventeen countries have reported increases in influenza-like illness (ILI) and/or ARI consultations (defined as countries with increases in the previous three weeks). These increases are particularly notable in the group aged 514 years. In eight of these countries (Germany, the Netherlands, Norway, Republic of Moldova, Romania, Slovakia, Spain and Sweden), the positivity rate of sentinel swab specimens exceeded 20% (minimum number of tested sentinel specimens: 20).

      The intensity of clinical activity was described as very high in Norway, Sweden, Bulgaria and the Republic of Moldova for the first time. Other countries reporting continued very high intensity this week were Iceland, Ireland and the Russian Federation (Urals region and far eastern region). Eight countries/regions described high clinical activity: Belarus, Finland, Kazakhstan, Poland, Russian Federation (central, north-western, Siberian and Volga region), Turkey, Ukraine and Northern Ireland. The clinical incidence of ILI and/or ARI was reported as widespread in 19 countries.

      The Republic of Moldova reported very high intensity, widespread clinical incidence and severe impact of influenza on health services.

      Impact was reported as moderate in nine countries, including Ukraine, and low in 17 others. For an overview of the season so far, click here.

      Increased clinical illness was reported in Bulgaria and the Republic of Moldova. In Bulgaria, incidence rates were above the epidemic threshold in 10 out of 28 regions. The incidence was highest in children. Current rates are similar to those reported in the 2006-2007 influenza season.

      For the Republic of Moldova, 555 specimens out of 1141 tested were positive for pandemic (H1N1) 2009 (including five fatal cases).

      While clinical influenza activity has increased over the past weeks in 17 countries, it has passed its peak in Belgium, Iceland, and Ireland, and has levelled off or passed its peak in the United Kingdom. Low or medium levels of influenza activity are reported in southern Russian Federation, Azerbaijan, Georgia, the Baltic states, the Czech Republic and Slovakia and in most of these countries incidence is increasing.

      In the period 512 November, 18 countries reported 145 new deaths associated with laboratory-confirmed pandemic (H1N1) 2009, raising the total since April 2009 from 326 to 471. The deaths were in Bulgaria (9), Croatia (2), Finland (5), France (4), Germany (3), Greece (2), Hungary (1), Ireland (2), Israel (8), Italy (34), the Netherlands (13), Norway (3), the Republic of Moldova (3), Serbia (6), Slovenia (1), Sweden (1), Turkey (31) and the United Kingdom (17).


      Virological update: week 45/2009


      Of the 27 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 3.5% (Georgia) to 68.3% (Bosnia and Herzegovina). Ten of these countries reported rates greater than 50%. Sentinel physicians in the Region collected 4129 respiratory specimens in week 45/2009, of which 1853 (45%) were positive for influenza virus. Of the 1853 influenza-virus detections, 1845 were type A (1781 pandemic A(H1) and 64 not subtyped) and 8 were type B.

      In addition, 11 311 non-sentinel-source specimens were reported positive for influenza virus in week 45/2009: 11 292 type A (9682 pandemic A(H1), 25 A(H3), 14 seasonal A(H1), 1571 not subtyped) and 19 type B.

      Of the total 36 087 specimens that have tested positive for influenza virus since week 40/2009, 30 308 (84%) were pandemic influenza A(H1) and these accounted for 99% of all influenza A viruses that were subtyped. In addition, 213 were seasonal influenza A(H1); 113 were influenza A(H3); 5366 were influenza A not subtyped; and 87 were influenza B. The number of influenza detections has risen sharply each week from about 1600 in week 40/2009 to over 13 000 in week 45/2009.


      Comment

      A total of 14 countries have reported high or very high intensity of influenza activity. A generally increasing trend in clinical data is confirmed by an increase in virological influenza detections. Notably, countries in Scandinavia, and eastern and south-eastern Europe are affected by the pandemic. Influenza detections far exceed historical peaks and indicate a surge of work in the laboratories in several countries. The pandemic (H1N1) 2009 virus is dominant and continues to account for high levels of influenza activity for the time of year. Reports are widespread of pressure on intensive care facilities.

      As of week 45/2009, 16 countries have started pandemic influenza vaccination campaigns. Reports of adverse events are fewer than reported for seasonal influenza vaccination and most events are mild local or systemic reactions. Eight countries in the Region are eligible to receive vaccine donated to WHO and this will begin by late November or early December 2009.


      Further information

      The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.


      Erratum:

      The percentage positive for Denmark in the table below is incorrect. A total of 38 sentinel specimens were collected of which 22 (58%) were positive for pandemic (H1N1) 2009.

      (...)
      -
      <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

      Comment


      • #33
        Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

        EuroFlu - Weekly Electronic Bulletin Week 46 : 09/11/2009-15/11/2009 - 20 November 2009, Issue N 332 (edited)
        EuroFlu - Weekly Electronic Bulletin Week 46 : 09/11/2009-15/11/2009 - 20 November 2009, Issue N 332

        Influenza activity remains high and is widespread across much of the European Region


        Key points: week 46/2009
        • This report is based on material received from 43 of the 53 Member States in the WHO European Region and includes an update on the situation in Ukraine.
        • 42% of specimens collected from sentinel sources in the Region tested positive for influenza virus.
        • The incidence of clinical respiratory illness has increased in 13 countries over the past 3 weeks. For 10 of these, the proportion of sentinel specimens testing positive for influenza this week was 20% or greater.
        • Countries throughout the Region reported high or very high intensity of influenza.
        • Pandemic (H1N1) 2009 was dominant in 36 countries and accounted for 99.2% of influenza A virus subtype detections.
        • From 13 to 20 November 2009, 21 countries reported a total of 181 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection.


        Ukraine

        Preliminary analyses of samples taken from patients in Ukraine show that the virus is similar to that used for production of the pandemic (H1N1) 2009 vaccine. Although influenza activity in Ukraine remains high, the incidence of acute respiratory infection (ARI) is lower than that reported last week.


        Current situation: week 46/2009

        Thirteen countries have reported increases in influenza-like illness (ILI) and/or ARI consultations (defined as countries with increases in the previous three weeks). These increases are particularly notable in the groups aged 04 and 514 years. In 11 of these countries (the Czech Republic, Estonia, Germany, Israel, the Netherlands, Poland, Portugal, the Republic of Moldova, Slovakia, Spain and Sweden), the positivity rate of sentinel swab specimens exceeded 20% (minimum number of tested sentinel specimens: 20).

        The intensity of clinical activity was described as very high in Italy (for the first time this season), Norway, the Republic of Moldova, the Russian Federation (Urals region) and Sweden. In addition, 14 countries reported high intensity. ILI and/or ARI was reported as geographically widespread in 24 countries. The impact on health services was described as severe in 2 countries (Albania, the Republic of Moldova), moderate in 11 and low in 16 others. For an overview of the season so far, see season tables.

        While clinical influenza activity has increased over recent weeks in 13 countries, it has passed its peak in Belgium, Iceland, Ireland and parts of the United Kingdom (England and Northern Ireland). Five countries showed a decrease in clinical influenza activity during the past week: Bulgaria, Romania, the Russian Federation (in the central, far eastern and Urals regions), Serbia and Ukraine. Medium levels of influenza activity were reported in 22 countries, mainly in western and central Europe and the Baltic states. One country (Slovakia) reported low activity this week.

        In the period 1320 November, 21 countries reported 181 new deaths associated with laboratory-confirmed pandemic (H1N1) 2009 influenza, raising the total since April 2009 from 471 to 652. The deaths were reported in Belgium (4), Croatia (2), Finland (3), France (14), Germany (7), Greece (3), Ireland (1), Italy (24), Luxembourg (1), the Netherlands (5), Norway (5), Poland (2), Portugal (3), the Republic of Moldova (2), Serbia (6), Spain (34), Sweden (2), Switzerland (1), the former Yugoslav Republic of Macedonia, (1), Turkey (33) and the United Kingdom (28). Poland, Switzerland and the former Yugoslav Republic of Macedonia reported their first laboratory-confirmed deaths during this week. Most pandemic (H1N1) 2009 cases have resolved without complications.


        Virological update: week 46/2009

        Of the 31 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 3.1% (Azerbaijan) to 78.6% (Slovenia). Fifteen of these countries reported rates greater than 50%. Sentinel physicians in the Region collected 6179 respiratory specimens this week, of which 2602 (42.1%) were positive for influenza virus. Of these virus detections, 2591 were type A (2490 pandemic A(H1) and 90 not subtyped) and 11 were type B.

        In addition, 16 794 non-sentinel-source specimens were reported positive for influenza virus in week 46/2009: 16 782 type A (15 468 pandemic A(H1), 65 A(H3), 76 seasonal A(H1), 1173 not subtyped) and 12 type B.

        Of the total of 59 434 specimens that have tested positive for influenza virus since week 40/2009, 51 936 (87.4%) were pandemic influenza A(H1) and these accounted for 99% of all influenza A viruses that were subtyped. In addition, 291 were seasonal influenza A(H1); 191 were influenza A(H3); 6900 were influenza A not subtyped; and 116 were influenza B. The number of influenza detections has risen sharply each week, from about 1 600 in week 40/2009, with 18% of sentinel specimens testing positive, to over 19 000 in week 46/2009, when 45% of sentinel specimens tested positive.


        Comment

        The pandemic is affecting all countries in the Region, and the intensity is high in 18, especially in children up to the age of 15. In three countries in western Europe the epidemic has passed its peak. In some countries reporting reduced activity, this may have been associated with school closures. Increasing clinical incidence has been corroborated by increases in virological influenza detections. Influenza detections continue to be far higher than historical peaks, and countries are recommended to prioritize their testing strategies to reduce the burden on national influenza centres and therefore national influenza surveillance systems.

        As of week 46/2009, 17 countries had started vaccination campaigns against pandemic (H1N1) 2009 influenza. Reports of adverse events are fewer than for seasonal influenza vaccination, and most events are mild local or systemic reactions. Eight countries in the Region are eligible to receive vaccine donated to WHO and distribution will begin by late November or early December 2009.


        Further information

        The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.


        Erratum

        The clinical data for Belarus for week 45/2009 were incorrect and have been corrected in this weeks bulletin.
        (...)
        -
        -----
        <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

        Comment


        • #34
          Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

          EuroFlu - Weekly Electronic Bulletin Week 47 : 16/11/2009-22/11/2009 - 27 November 2009, Issue N 333 (edited)

          EuroFlu - Weekly Electronic Bulletin Week 47 : 16/11/2009-22/11/2009 - 27 November 2009, Issue N 333


          High influenza activity in the European Region

          Key points: week 47/2009
          • This report is based on data received from 43 of the 53 Member States in the WHO European Region, and includes an update on the situation in Ukraine.
          • 37% of specimens collected from sentinel sources in the Region tested positive for influenza virus.
          • The incidence of clinical respiratory illness has increased in 16 countries over the past 3 weeks. Out of 12 countries that tested at a least 20 samples, 10 reported that 20% or more of sentinel specimens had tested positive for influenza.
          • Countries throughout the Region reported high or very high intensity of influenza, with Albania and the Republic of Moldova reporting severe impact on health services.
          • Pandemic (H1N1) 2009 was dominant in 38 countries and accounted for 98.8% of influenza A virus subtype detections.
          • From 20 to 26 November 2009, 25 countries reported a total of 267 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection.


          Ukraine

          Overall influenza activity appears to be decreasing. Preliminary tests of samples taken from patients in Ukraine reveal no significant changes in the pandemic (H1N1) 2009 virus. Analyses are being performed by two WHO influenza collaborating centres as part of the global influenza surveillance network.


          Current situation: week 47/2009

          Sixteen countries have reported increases in influenza-like illness (ILI) and/or acute respiratory infection (ARI) consultations (defined as countries with increases in the previous three weeks). These increases are particularly notable in the groups aged 04 and 514 years. In 10 of these countries (Austria, the Czech Republic, Estonia, Germany, Greece, Latvia, Slovakia, Spain, Sweden and Switzerland) the positivity rate of sentinel swab specimens exceeded 20% (minimum number of tested sentinel specimens per country: 20).

          The intensity of clinical activity was described as very high in the Republic of Moldova, the Russian Federation (north-western, Siberian and Volga regions) and Sweden. Nineteen countries reported high intensity.

          Twenty-three reported ILI and/or ARI as geographically widespread.

          The impact on health services was described as severe in 2 countries (Albania, the Republic of Moldova), moderate in 15 and low in 12 others.

          For an overview of the season so far, see season tables.

          While clinical influenza activity has increased over recent weeks in 16 countries, it appears to have passed its peak in Belgium, Iceland, Ireland, Ukraine and parts of the United Kingdom (Northern Ireland, Wales).

          Data for week 47 also indicate decreased activity in Bulgaria, Israel, the Netherlands, Norway and Serbia. In Germany and Spain, clinical activity is levelling off, which may indicate that it will peak soon.

          In the period 2026 November, 25 countries reported 267 new deaths associated with laboratory-confirmed pandemic (H1N1) 2009, raising the total number of deaths since April 2009 from to 919. The deaths were reported by Belgium (1), Croatia (6), the Czech Republic (1), Denmark (4), Finland (3), France (36), Germany (30), Greece (4), Hungary (3), Israel (11), Italy (20), the Netherlands (7), Norway (4), Portugal (8), the Republic of Moldova (4), Romania (2), the Russian Federation (6), Serbia (4), Slovakia (1), Slovenia (1), Spain (27), Sweden (9), Switzerland (2),Turkey (39) and the United Kingdom (34).

          Romania and Slovakia reported their first laboratory-confirmed deaths during this week.

          In Norway, mutation was detected in three samples of pandemic (H1N1) 2009 virus. They were isolated from the first two fatal cases in the country and one patient with severe illness. Norwegian scientists have analysed samples from more than 70 patients with clinical illness and no further instances of this mutation have been detected. For further information, see Pandemic (H1N1) 2009 briefing note 17.

          A cluster of cases of oseltamivir-resistant pandemic (H1N1) 2009 virus infections among patients in a hospital ward in Wales has been reported to WHO. No further spread has been observed and the virus remained susceptible to zanamivir. For further information, see the National Public Health Service for Wales.


          Virological update: week 47/2009

          Of the 34 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 0% (Croatia) to 83% (Lithuania). Sentinel physicians in the Region collected 5959 respiratory specimens this week, of which 2221 (37%) were positive for influenza virus. Of these virus detections, 2216 were type A (2041 pandemic A(H1) and 175 not subtyped) and 5 were type B.

          In addition, 14 294 non-sentinel specimens were reported positive for influenza virus in week 47/2009: 14 242 type A (12 817 pandemic A(H1), 83 A(H3), 102 seasonal A(H1), 1240 not subtyped) and 52 type B.

          Of the 77 816 specimens that have tested positive for influenza virus since week 40/2009, 68 634 (88%) were pandemic influenza A(H1) and these accounted for 99% of all influenza A viruses subtyped. In addition, 394 were seasonal influenza A(H1); 282 were influenza A(H3); 8336 were influenza A not subtyped; and 170 were influenza B. The number of influenza detections rose sharply from week 40/2009 (about 1600, with 18% of sentinel specimens testing positive), to week 46/2009 (over 19 000, with 45% of sentinel specimens testing positive) but decreased in week 47/2009 (16 515 with 37% of sentinel specimens testing positive).

          Based on the genetic characterization of 156 influenza viruses reported from week 40/2009 to week 47/2009, all (100%) were pandemic A(H1N1), A/California/7/2009-like.

          Seven countries have tested isolates of pandemic (H1N1) 2009 virus for antiviral resistance. Of the 904 cases tested, 4 were resistant to oseltamivir.


          Comment

          Despite the decrease in influenza virus detections in week 47/2009, the pandemic is affecting most countries in the Region, with the greatest incidence in children up to the age of 15. High or very high intensity was reported in 22 countries. While influenza activity continued to increase in 16 countries, decreasing levels have been observed in 10. The vast majority of influenza viruses detected were pandemic (H1N1) 2009.

          The percentage of positive sentinel specimens and the total number of influenza detections slightly decreased in week 47/2009. Less testing is desirable in order to focus on confirmation of severe cases as well as analyses of samples from cases where treatment fails.

          A WHO Collaborating Centre for International Drug Monitoring, the Uppsala Monitoring Centre, in Sweden, has set up a web page on influenza vaccine monitoring.


          Further information

          The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.
          (...)
          -
          <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

          Comment


          • #35
            Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

            EuroFlu - Weekly Electronic Bulletin Week 48 : 23/11/2009-29/11/2009 - 04 December 2009, Issue N 334 (Extracts, edited)
            EuroFlu - Weekly Electronic Bulletin Week 48 : 23/11/2009-29/11/2009 - 04 December 2009, Issue N 334

            Increasing influenza activity in central and south-eastern Europe


            Key points: week 48/2009
            • This report is based on data received from 46 of the 53 Member States in the WHO European Region.
            • 38% of specimens collected from sentinel sources in the European Region tested positive for influenza virus.
            • Over the past 3 weeks, the incidence of clinical respiratory illness has increased in 9 countries, mostly in central and south-eastern Europe, and decreased in 6 others.
            • Out of 28 countries that tested at least 20 sentinel specimens for influenza, 23 reported that 30% or more had tested positive for influenza.
            • 19 countries throughout the European Region reported high or very high intensity of influenza, with 13 reporting a moderate impact on health services.
            • Pandemic (H1N1) 2009 was dominant in 35 countries and accounted for nearly 100% of influenza A virus subtype detections in sentinel specimens and 98% of detections in non-sentinel specimens.
            • From 27 November to 3 December, 29 countries reported a total of 324 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection.


            Current situation: week 48/2009

            Nine countries reported increases in influenza-like illness (ILI) and/or acute respiratory infection (ARI) consultations (defined as countries with increases in the previous three weeks). Increasing influenza activity is most notable in central and south-eastern Europe, as the countries reporting increases are Albania, the Czech Republic, Estonia, Greece, Hungary, Latvia, Poland, the Republic of Moldova and Slovenia.

            These countries also appear to be reporting relatively sharper increases in consultation rates in the group aged 514 years than in the group aged 04. Of these countries, 7 tested at least 20 sentinel specimens and have reported a mean influenza positivity rate of 47% (median 45%) with a range of 1374%.

            The intensity of clinical activity was described as very high in two countries (Greece and Lithuania) and the Siberian region of the Russian Federation. Seventeen countries reported high intensity. Twenty-six reported ILI and/or ARI as geographically widespread.

            The impact on health services was described as moderate in 13 countries.

            Clinical respiratory disease activity has declined over the past three weeks in Belgium, Iceland, Ireland, Norway, Serbia and Ukraine. With the exception of Iceland, these countries experienced rapid increases in clinical consultation rates associated with influenza virus circulation during the time since week 40, and reached peaks 34 weeks after the initial increases were observed. While consultation rates have subsequently declined somewhat more precipitously in Ukraine than the other countries, several regions in the eastern and western parts of Ukraine continue to report a medium intensity of influenza circulation and a moderate impact on health services.

            From 27 November to 3 December, 29 countries reported a total of 324 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection. This raises the total number of deaths reported since April 2009 from 919 to 1243. Austria, Latvia and Lithuania reported their first such deaths during this week.


            Virological update: week 48/2009

            Sentinel physicians collected 4224 respiratory specimens this week, of which 1606 (38%) were positive for influenza virus. Of these virus detections, 1604 were type A (1481 pandemic A(H1), 118 not subtyped and 5 influenza A(H3)) and 2 were type B. Of the 28 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 2% (Azerbaijan) to 100% (Austria) with a median of 39%, and a mean of 44%.

            In addition, 11 376 non-sentinel specimens were reported positive for influenza virus in week 48/2009: 11 335 type A (10 017 pandemic A(H1), 65 A(H3), 104 seasonal A(H1), 1149 not subtyped) and 41 type B.

            Based on the antigenic characterization of 238 influenza viruses reported from week 40/2009 to week 48/2009, 237 were pandemic A(H1N1), A/California/7/2009-like and 1 was B/Brisbane/60/2008-like.

            Genetic characterization of 95 of the pandemic viruses indicated that all were in the pandemic cluster represented by A/California/7/2009

            Of the total of 89 129 specimens that have tested positive for influenza virus since week 40/2009, 78 614 (88.2%) were pandemic influenza A(H1) and these accounted for 99% of all influenza A viruses that were subtyped. In addition, 498 viruses were seasonal influenza A(H1); 340 were influenza A(H3); 9466 were influenza A not subtyped; and 211 were influenza B.

            Seven countries have tested isolates of pandemic (H1N1) 2009 virus for oseltamivir resistance. Of the 935 cases tested, 10 were resistant to oseltamivir. All viruses tested for resistance to zanamivir (282/282) have been found to be zanamivir-sensitive and all viruses tested for resistance to adamantanes (64/64) have been found to be resistant.


            Comment

            The pandemic is affecting most countries in the WHO European Region, with some indication that central and south-eastern countries are currently experiencing the greatest intensity of influenza activity. The emergence of the pandemic (H1N1) 2009 virus has produced a level of influenza activity that is unusual for this time of year in Europe, as the proportion of sentinel specimens testing positive for influenza has ranged from 1% to 9% during week 48 over the previous 5 years. High or very high intensity of influenza and respiratory illness activity was reported in 19 countries, although 6 countries now appear to be past their initial peaks in disease activity


            Further information

            The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.
            (...)
            -
            -----
            <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

            Comment


            • #36
              Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

              EuroFlu - Weekly Electronic Bulletin Week 49 : 30/11/2009-06/12/2009 - 11 December 2009, Issue N 335 (edited)
              EuroFlu - Weekly Electronic Bulletin Week 49 : 30/11/2009-06/12/2009 - 11 December 2009, Issue N 335

              Heterogeneous pandemic influenza activity across the European Region


              Key points: week 49/2009
              • This report is based on data received from 40 of the 53 Member States in the WHO European Region.
              • 35% of specimens collected from sentinel sources in the European Region tested positive for influenza virus.
              • Over the past 3 weeks, the incidence of clinical respiratory illness has increased in 6 countries and decreased in 10 others.
              • Out of 28 countries that tested at least 20 samples, 16 reported that 30% or more of sentinel specimens had tested positive for influenza.
              • 15 countries throughout the European Region reported high or very high intensity of influenza, with 7 of these reporting a moderate impact on health services.
              • Pandemic (H1N1) 2009 was dominant in 33 countries and accounted for nearly 100% of influenza A virus subtype detections in sentinel specimens and over 98% of detections in non-sentinel specimens.
              • From 4 to 10 December, 27 countries reported a total of 412 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection.


              Current situation: week 49/2009

              Six countries (Czech Republic, Estonia, France, Hungary, Montenegro and Switzerland) reported increases in influenza-like illness (ILI) and/or acute respiratory infection (ARI) consultations (defined as countries with increases in each of the previous three weeks). Of these countries, 5 tested at least 20 sentinel specimens and have reported a mean influenza positivity rate of 51% (median 54%) with a range of 2871%.

              Clinical respiratory disease activity has declined over the past 3 weeks in 10 countries (Belgium, Bulgaria, Iceland, Ireland, Israel, the Netherlands, Norway, Portugal, Sweden and Ukraine). This decrease in clinical activity was confirmed by the virological data, with a general decreasing trend in the percentage of positive specimens in 8 out of 10 countries. In week 47, the overall percentage of positive sentinel specimens was 44% (median) and decreased to 26% (median) in week 49.

              The intensity of clinical activity was described as very high in Lithuania, and 14 countries reported high intensity.

              Twenty-three countries reported ILI and/or ARI as geographically widespread.

              The impact on health services was described as moderate in 16 countries. None of the countries reported a severe impact.

              The Russian Federation has been reporting ARI deaths to the EuroFlu platform since week 43. From week 43 to week 49, it reported a total of 102 ARI deaths , of which the majority (n=41) were reported in week 48. Ninety-three percent of these deaths occurred in the population aged 15 to 64.

              From 4 to 10 December, 27 countries reported a total of 412 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection. This raises the total number of deaths reported since April 2009 from 1243 to 1655. Bosnia and Herzegovina, Estonia and Montenegro reported their first such deaths during this week.


              Virological update: week 49/2009

              Sentinel physicians collected 3437 respiratory specimens this week, of which 1190 (35%) were positive for influenza virus. Of these virus detections, 1188 were type A (1123 pandemic A(H1), 63 not subtyped, 1 influenza A(H1), 1 influenza A(H3)) and 2 were type B. Of the 28 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 4% (Iceland) to 71% (Czech Republic and Greece), with a mean of 35%.

              In addition, 9435 non-sentinel specimens were reported positive for influenza virus in week 49/2009: 9410 type A (8400 pandemic A(H1), 29 A(H3), 92 seasonal A(H1), 889 not subtyped) and 25 type B.

              Based on the antigenic characterization of 417 influenza viruses reported from week 40/2009 to week 49/2009, 416 were pandemic A(H1N1), A/California/7/2009-like and one was B/Brisbane/60/2008-like.

              Of the total of 105 773 specimens that have tested positive for influenza virus since week 40/2009, 93 965 (89%) were pandemic influenza A(H1) and these accounted for 99% of all influenza A viruses that were subtyped. In addition, 591 viruses were seasonal influenza A(H1); 374 were influenza A(H3); 10 608 were influenza A not subtyped; and 235 were influenza B.

              While over 400 specimens of pandemic H1N1 viruses have been characterized, none of the 1200 typed or subtyped seasonal influenza viruses were characterized in the period from week 40/2009 to week 49/2009 .

              For vaccine recommendation purposes, laboratories are encouraged to send seasonal influenza specimens (clinical samples or isolates) for characterization to the WHO Collaborating Centre for Reference and Research on Influenza in Mill Hill, London.

              Seven countries have tested isolates of pandemic (H1N1) 2009 virus for oseltamivir resistance. Of the 944 cases tested, 19 were resistant to oseltamivir. All viruses tested for resistance to zanamivir (282) have been found to be zanamivir-sensitive and all viruses tested for resistance to adamantanes (64) have been found to be resistant.

              In week 50 in the Netherlands, 11 patients were diagnosed with a mixture of oseltamivir resistant and wild-type pandemic A(H1N1) 2009 influenza viruses. In all cases this was found in a respiratory specimen following initiation of oseltamivir therapy, indicating that resistance emerged during therapy and not from infection with a resistant virus. Nine of the patients, four of whom died, were immunosuppressed due to chemotherapy/immunosuppressive therapy. Contact tracing identified no cases of onward transmission of the oseltamivir resistant viruses.


              Comment

              The pandemic is affecting most countries in the WHO European Region, with some indication that central and eastern countries are currently experiencing the greatest intensity of influenza activity. However, 10 countries also appear to have passed initial peaks in clinical activity, suggesting a heterogeneous picture of influenza intensity across the Region.


              Further information

              The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.
              (...)
              -
              <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

              Comment


              • #37
                Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

                EuroFlu - Weekly Electronic Bulletin Week 50 : 07/12/2009-13/12/2009 - 18 December 2009, Issue N 336 (edited)
                EuroFlu - Weekly Electronic Bulletin Week 50 : 07/12/2009-13/12/2009 - 18 December 2009, Issue N 336

                Declining trends in pandemic H1N1 2009 influenza activity in Europe


                Key points: week 50/2009
                • This report is based on data received from 41 of the 53 Member States in the WHO European Region.
                • 34% of specimens collected from sentinel sources in the European Region tested positive for influenza virus.
                • Over the past 3 weeks, the incidence of clinical respiratory illness has increased in 2 countries and decreased in 18 others.
                • Out of 27 countries that tested at least 20 samples, 10 reported that 30% or more of sentinel specimens had tested positive for influenza.
                • 9 countries throughout the European Region reported high or very high intensity of influenza, with 5 of these reporting a moderate impact on health services.
                • Pandemic (H1N1) 2009 was dominant in 32 countries and accounted for 100% of influenza A virus subtype detections in sentinel specimens and over 98% of detections in non-sentinel specimens.
                • From 11 to 17 December, 23 countries reported a total of 380 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection, bringing the total number of laboratory-confirmed deaths reported since April 2009 to 2045.


                Current situation: week 50/2009

                Two countries (Hungary and Montenegro) reported an increase in influenza-like illness (ILI) and/or acute respiratory infection (ARI) consultations (defined as countries with increases in each of the previous three weeks).

                Clinical respiratory disease activity has declined over the past 3 weeks in 18 countries; 12 of these countries tested over 20 sentinel specimens with an overall of 22% (median) positive specimens. In four countries (Georgia, Romania (ARI), Serbia, Ukraine), however, influenza activity has shown some signs of a resurgence following declining trends in previous weeks. This activity will continue to be monitored. In particular the eastern regions of Ukraine showed an increase in ARI rates in week 50.

                Thirty-three countries provided data on trends in clinical consultations by age. Eighteen countries reported highest rates among the group aged 514 years while the others reported highest rates in the group aged 04.

                The intensity of clinical activity was described as very high in Lithuania, and 6 countries reported high intensity; 17 reported ILI and/or ARI as geographically widespread.

                The impact on health services was described as moderate in 13 countries. None of the countries reported a severe impact.

                From 11 to 17 December, 23 countries reported a total of 390 deaths involving laboratory-confirmed cases of pandemic (H1N1) 2009 virus infection. This raises the total number of such deaths reported since April 2009 from 1655 to 2045.

                Albania and Georgia reported their first deaths related to pandemic (H1N1) 2009 influenza during the week.


                Virological update: week 50/2009

                Sentinel physicians collected 3225 respiratory specimens this week, of which 1096 (34%) were positive for influenza virus. Of these virus detections, all were type A (1040 pandemic A(H1), 56 not subtyped. Of the 27 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 0% (Finland and Turkey) to 71% (Greece), with a mean of 35% (median 17).

                In addition, 8850 (36%) of 24922 non-sentinel specimens were reported positive for influenza virus in week 50/2009: 8772 type A (8090 pandemic A(H1), 24 A(H3), 74 seasonal A(H1), 584 not subtyped) and 43 type B.

                Based on the antigenic characterization of 545 influenza viruses reported from week 40/2009 to week 50/2009, 542 were pandemic A(H1N1), A/California/7/2009-like, 2 were A(H3) A/Brisbane/10/2007 (H3N2)-like, and 1 was B/Brisbane/60/2008-like. Genetic characterizations were available for 204 isolates; all belonged to the A/California/7/2009 A(H1N1) pandemic influenza lineage.

                Of the total of 123 270 specimens that have tested positive for influenza virus since week 40/2009, 110 434 (90%) were pandemic influenza A(H1) and these accounted for 99% of all influenza A viruses that were subtyped. In addition, 665 viruses were seasonal influenza A(H1); 397 were influenza A(H3); 11 487 were influenza A not subtyped; and 287 were influenza B.

                Seven countries have tested isolates of pandemic (H1N1) 2009 virus for oseltamivir resistance. Of the 944 cases tested, 19 were resistant to oseltamivir. All viruses tested for resistance to zanamivir (282) have been found to be zanamivir-sensitive and all viruses tested for resistance to adamantanes (64) have been found to be resistant.


                Comment

                While influenza activity is increasing in 2 countries, an overall decreasing trend has been observed for 18. In general, ILI/ARI consultations and influenza detections peaked early this influenza season, around week 47/2009, with an early peak reported for England around week 30/2009. In the previous influenza season the peak was around week 4 (range: week 5212). Nevertheless, trends in clinical and virological data are being monitored to determine if additional waves of winter-time activity will occur, or the proportion of seasonal influenza viruses in circulation will change.


                Further information

                The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.
                (...)
                -
                <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

                Comment


                • #38
                  Re: EuroFlu - Weekly Electronic Bulletin - Influenza Surveillance

                  EuroFlu - Weekly Electronic Bulletin Week 51 : 14/12/2009-20/12/2009 - 25 December 2009, Issue N 337 (edited)
                  EuroFlu - Weekly Electronic Bulletin Week 51 : 14/12/2009-20/12/2009 - 25 December 2009, Issue N 337

                  Ongoing influenza activity despite declining clinical trends in many countries


                  Key points: week 51/2009
                  • This report is based on data received from 41 of the 53 Member States in the WHO European Region.
                  • Thirty-five per cent of specimens collected from sentinel sources tested positive for influenza virus.
                  • Over the past three weeks, the incidence of clinical respiratory illness has decreased in 20 countries and increased in two others.
                  • Out of 21 countries that reported testing at least 20 sentinel specimens for influenza, 13 reported that 30% of specimens or more had tested positive for influenza.
                  • Five countries reported high or very high intensity of influenza activity, with six reporting moderate or severe impact on health services.
                  • Pandemic (H1N1) 2009 was dominant in 32 countries and accounted 100% of influenza A virus subtype detections in sentinel specimens and 99% of detections in non-sentinel specimens.
                  • 2397 laboratory confirmed pandemic (H1N1) 2009 deaths have been reported in the Region.


                  Current situation: week 51/2009

                  Clinical respiratory disease activity has declined over the past three weeks in 20 countries. However, nine of these countries also tested at least 20 sentinel specimens for influenza during week 51/2009 and the median influenza positivity rate was 39% (mean 34%), suggesting that influenza circulation is ongoing despite declining clinical trends. Two countries, Georgia and Montenegro, have reported recent and substantial increases in influenza-like illness (ILI) (defined as increases in each of the previous three weeks). In Georgia, 66% of sentinel specimens tested positive for influenza this week, reflecting the highest positivity rate of any country testing 20 or more sentinel specimens. Qualitative reporting also suggests that there are still parts of the WHO European Region where transmission remains intense. Bulgaria, Greece, Poland, the Russian Federation (Urals Region) and Serbia reported the intensity of influenza circulation as high, and Georgia reported the intensity as very high. France, Hungary, Kyrgyzstan, Romania and Turkey reported the impact of influenza on health care services to be moderate, and Georgia reported the impact to be severe.

                  Reports of respiratory hospitalizations and deaths submitted to EuroFlu also reflect mixed trends in severe respiratory disease activity. Reports of deaths due to acute respiratory infection (ARI) received from the Russian Federation have declined each week since week 48/2009, reflecting a pattern similar to observed trends in ARI consultations. The weekly count of hospitalizations due to severe acute respiratory illness (SARI) reported by Kyrgyzstan has also decreased from a peak that was observed in week 47. However, three SARI sentinel surveillance sites in Ukraine have reported notable increases in hospitalized SARI cases in week 51. Similarly, weekly reports of SARI hospitalizations in Uzbekistan rose steadily between weeks 45 and 49, declined in week 50, but have again increased in week 51/2009.


                  Virological update: week 51/2009

                  Sentinel physicians collected 2340 respiratory specimens this week, of which 817 (35%) were positive for influenza virus. Of these virus detections, 816 were type A (802 pandemic A(H1), 14 not subtyped) and 1 was type B. Of the 21 countries testing 20 or more sentinel specimens this week, influenza-positive rates ranged from 0% (Azerbaijan) to 66% (Georgia), with a median of 38% and a mean of 35%.

                  In addition, 6434 non-sentinel specimens were reported to be positive for influenza virus in week 51/2009: 6420 type A (6053 pandemic A(H1), 17 A(H3), 45 seasonal A(H1), 305 not subtyped) and 14 type B. Based on the antigenic characterization of 799 influenza viruses reported from week 40/2009 to week 51/2009, 792 were pandemic A(H1N1), A/California/7/2009-like, 3 were A/Perth/16/2009 (H3N2)-like, 2 were A(H3) A/Brisbane/10/2007 (H3N2)-like, 1 was A/Brisbane/59/2007 (H1N1)-like, and 1 was B/Brisbane/60/2008-like. Genetic characterizations were available for 204 isolates; all belonged to the A/California/7/2009 A(H1N1) pandemic influenza lineage.

                  Ten countries have tested isolates of pandemic (H1N1) 2009 virus for oseltamivir resistance. Of the 1312 cases tested, 26 were resistant to oseltamivir. All viruses tested for resistance to zanamivir (346/346) have been found to be zanamivir-sensitive and all viruses tested for resistance to adamantanes (64/64) have been found to be resistant.


                  Comment

                  Sentinel surveillance systems throughout the Region suggest that influenza activity remains ongoing despite declining trends in clinical activity in many countries. The percentage of sentinel specimens testing positive for influenza in the Region reached 45% during week 45/2009 but has since remained between 34 and 42%. While some countries now appear to be past their initial peaks in disease activity, other countries are currently experiencing high levels of winter season influenza transmission.


                  Further information

                  The EuroFlu bulletin describes and comments on influenza activity in the 53 countries in the WHO European Region. Further information can be obtained from the WHO/Europe and WHO headquarters web sites.
                  (...)
                  -
                  <cite cite="http://www.euroflu.org/cgi-files/bulletin_v2.cgi">EuroFlu - Bulletin Review</cite>

                  Comment

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