Swine flu has jumped continents.Associated PressA new strain of swine flu - influenza A (H1N1) - is spreading around the globe. This timeline will be continually updated with key dates, drawing on authoritative information from the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC) and other sources. For more on the situation see the Nature News swine flu special, and read updates on The Great Beyond blog.
19 November 2009 : China says it has dispatched monitoring teams to 12 regions after a high profile doctor suggested some cases of H1N1 might be being deliberately not reported.
After around 65 million people have been vaccinated, the WHO says H1N1 vaccines appear to have an "excellent safety profile". None of the deaths investigated in those vaccinated have found a direct link to vaccination.
2 November 2009 : Ministry of Health of Ukraine reports it has recorded over 250,000 cases of influenza-like illness, with 70 deaths.
1 November 2009 : WHO reports that more than 199 countries and overseas territories have laboratory confirmed cases of H1N1, with over 6,000 recorded deaths.
30 October 2009 : Strategic Advisory Group of Experts (SAGE) on Immunization issues vaccination advice to the WHO, including use of a single dose of vaccine in adults and adolescents and use of any licensed vaccine for pregnant women.
27 October 2009: Russian media reports the country's first H1N1 deaths.
25 October 2009 : This week: vaccinations get underway in many European countries.
18 October 2009 : This week, Mongolia, Rwanda, and Sao Tome and Principe issue first reports of H1N1 and Iceland, Sudan, and Trinidad and Tobago reported their first deaths.
30 September 2009 : Australia begins mass swine flu vaccinations.
25 September 2009 : European Medicines Agency recommends approval of two H1N1 vaccines, from Novartis and GlaxoSmithKline.
15 September 2009 : FDA approves four H1N1 vaccines, from CSL Limited, MedImmune LLC, Novartis, and Sanofi Pasteur.
10 September 2009 : Two papers published in the New England Journal of Medicine show two new vaccines against H1N1 are likely to be effective after just one dose (paper 1, paper 2).
"The obvious advantage of a one-dose schedule is that, in the current time of vaccine scarcity, it doubles the number of people who may be vaccinated with a fixed amount of vaccine," writes Kathleen Neuzil, of PATH, in an accompanying editorial. "On the basis of these data, it would be appropriate to begin vaccination with the use of one dose of the usual antigen content."
3 September 2009 : Novartis says a trial on 100 subjects shows its H1N1 vaccine is "potentially protective" for 80% of subjects after one dose and over 90% after two doses.
21 August 2009 : Healthy victims of swine flu should not routinely be given antiviral drugs, the World Health Organization warns.
3 August 2009 : India confirms first death from H1N1, the victim being a 14-year old girl in the city of Pune.
29 July 2009 : Researchers from the US Centers for Disease Control and Prevention warn that pregnant women "might be at increased risk for complications from pandemic H1N1" in a research paper in The Lancet (more on this story).
28 July 2009 : The death of a 22 year old university student in South Africa marks the first death in sub-Saharan Africa. Confirmation of H1N1 as the cause comes 3 August.
22 July 2009 : Two Australian companies say they have started human trials of their swine flu vaccines.
16 July 2009 : WHO changes reporting requirements for H1N1 and abandons issuing global tables with numbers of confirmed cases for all countries.
It notes that the increasing number of cases "is making it extremely difficult, if not impossible, for countries to try and confirm them through laboratory testing".
8 July 2009 : WHO says the three incidences of drug resistant H1N1 to date are "sporadic cases" of resistance. "At this time, there is no evidence to indicate the development of widespread antiviral resistance among pandemic H1N1 viruses."
2 July 2009: Japan's health ministry reports that it too has detected a case of Tamiflu resistant H1N1.
The UK moves its swine flu response from 'containment' to 'treatment'. "Our national focus should be on treating the increasing numbers affected by swine flu," says health minister Andy Burnham.
29 June 2009: The first case of Tamiflu resistant swine flu has been reported in Denmark
24 June 2009: Argentinian authorities report that a pig at a pig farm in Buenos Aires province has tested positive for the novel H1N1 strain, making it only the second known swine infection outside of Canada.
22 June 2009: Chinese state news source Xinhua reports tests have begun on the first H1N1 vaccine developed in the country.
19 June 2009: South Africa confirms its first case of swine flu - offically marking the disease's spread into sub-Saharan Africa.
14 June 2009: The first swine flu death in Europe has been reported. A woman in Scotland who died with H1N1 had "underlying health conditions", according to the Scottish government.
11 June 2009: Phase 6 has been declared. The world is in a full-blown influenza pandemic for the first time in 41 years.
9 June 2009: The WHO reports that Inuit communities in Canada may be particularly hard-hit. It continues to face questions as to why a full-blown pandemic has not been declared.
8 June 2009: The WHO adds a death in the Dominican Republic to its list, bringing the number of countries that have reported deaths to six.
3 June 2009: H1N1 has reached Africa. The WHO has confirmed a case in Egypt.
Cases in Australia stand at 501, the largest number outside of the Americas.
A report in Eurosurveillance estimates a reproduction number for the virus — the average number of secondary cases generated by a single primary case — of 2.3 in Japan. That's higher than estimates from elsewhere.
The CDC's Morbidity and Mortality Weekly Report suggests that the outbreak in Mexico may have peaked in late April.
2 June 2009: The WHO says it is inching closer to moving its pandemic alert status to phase 6, which would denote official global pandemic status.
1 June 2009: June opens with 17,410 cases reported in 62 countries, including newbies like the Bahamas and Estonia. The death toll in Mexico stands at 97.
In the US there are or have been cases in all 50 states, including 17 deaths, according to the CDC. MedImmune, a biotechnology firm in Gaithersburg, Maryland, wins a $90 million contract from the federal government to begin developing a live attenuated vaccine for H1N1.
27 May 2009: A New England Journal of Medicine article argues, in response to suggestions that the WHO evaluate its criteria for moving to phase 6 and declaring a pandemic, that "the global extent of a pandemic should be described objectively and should be just one factor in decisions about how to respond."
22 May 2009: Australia raises its alert level to 'Contain', even as the Mexican government relaxes its restrictions in Mexico City.
20 May 2009: Worldwide case numbers have passed the scientifically meaningless but impressive sounding 10,000-case mark. Total number: 10,243.
18 May 2009: The day it confirmed that 8,829 H1N1 cases have been reported in 40 countries, the WHO has cautioned against complacency.
"This virus may have given us a grace period, but we do not know how long this grace period will last," said Margaret Chan, WHO director-general. "No one can say whether this is just the calm before the storm."
However the pandemic alert level is still at five today, one level below a full pandemic.
13 May 2009: As of this morning, 33 countries have reported 5,728 cases of H1N1 to the WHO.
12 May 2009: The CDC notes that it is seeing some severe complications in cases of H1N1 in pregnant women, including one death in the US.
11 May 2009: The WHO has confirmed swine flu deaths in Canada and Costa Rica, bringing the total number of countries where fatalities have occurred to four.
Mexico has reported 48 deaths and the United States three. Worldwide, 30 countries have officially reported 4694 cases.
A modeling study in Science suggests that the virus spreads at a rate comparable to that of previous influenza pandemics.
8 May 2009: Brazil reports four cases, bringing the number of affected countries to 25. Deaths now stand at 44 worldwide, with 2,500 confirmed cases. Most newly reported cases in new areas, the WHO says, come from travelers returning from affected areas. The CDC reports that hospitalization rates in the US are coming down, to 3.5%, as testing expands to include milder cases.
The Harvard School of Public Health releases a poll in which 83% of Americans polled say they are satisfied with the way public health officials have managed the outbreak. Still, 48% of parents with children in school think they or a family member will come down with H1N1 in the next year.
7 May 2009: Worldwide confirmed cases are now at 2,371.
6 May 2009: WHO confirms swine flu cases in Sweden and Guatemala.
5 May 2009: Mexico's H1N1 shutdown should begin to ease tomorrow, with restaurants and cafes set to reopen.
The latest WHO figures say the virus has now spread to 21 countries. Mexico has reported 590 cases and 25 deaths while the United States has reported 286 cases and one death.
However, the Texas Department of State Health Services has confirmed a second person has died in the United States. The DSHS says a woman with "chronic underlying health conditions" died earlier this week.
The following countries have reported cases but no deaths: Austria, Canada, China (Hong Kong Special Administrative Region), Costa Rica, Colombia, Denmark, El Salvador, France, Germany, Ireland, Israel, Italy, Netherlands, New Zealand, Portugal, Republic of Korea, Spain, Switzerland and the United Kingdom.
4 May 2009: Colombia joins the club. There are now 985 cases in 20 countries. Mexico is up to 25 deaths, but officials there say the disease seems to be on the decline.
3 May 2009: Ireland and Italy each report one case. 898 cases are now reported.
2 May 2009: China (Hong Kong special administrative region), Costa Rica, Denmark, France, and the Republic of Korea join the list. Total cases reported to the WHO are now at 658 in 16 countries.
Canadian authorities announce that H1N1 has been detected in a swine herd in Alberta. The pigs likely caught the virus from a Canadian who had recently visited Mexico, making this the first known case of human-to-animal transmission.
1 May 2009: As of this morning, 331 cases of H1N1 have been reported in 11 countries. According to the WHO, the worst outbreaks are still in Mexico (156 cases and nine deaths) and the United States (109 cases and one death).
30 April 2009: Austria, Switzerland and the Netherlands join the WHO list of countries with confirmed cases. The agency also announces it will refer to the virus not as swine flu but as influenza A(H1N1).
29 April 2009: The WHO raises pandemic level alert to phase 5, "a strong signal that a pandemic is imminent". First swine-flu death outside Mexico reported as a baby dies in Texas. Germany joins European countries with H1N1 and confirms three swine flu cases. The WHO confirms 7 more cases in Canada, bringing the total number there to 13.
28 April 2009: Seven countries are now reporting confirmed cases of H1N1 swine flu: the United States, Mexico, Canada, New Zealand, the United Kingdom, Israel and Spain.
27 April 2009: Canada reports six cases of swine flu and Spain reports one. In the United States 40 people have flu confirmed. In Mexico 26 cases are confirmed, with 7 deaths resulting. Estimates for the true number of deaths hover around 80.
The WHO raises pandemic alert level to 4 having confirmed human-to-human transmission able to cause 'community-level outbreaks'. "Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion," says the organisation.
25 April 2009: WHO director-general, Margaret Chan calls the flu problem "a public health emergency of international concern ".
23 April 2009: Officials issue orders to close schools in Mexico City, beginning a process of limiting public crowds. Three major soccer [futbol] games around Mexico City close stadium gates to all fans the weekend of April 25-26, with games broadcast on television. Stadium closures continue through May 2-3.
21 April 2009: CDC laboratories confirm two cases in California. Three additional cases confirmed the next day, with two more in Texas added the day after.
28 March 2009: Earliest onset date of swine flu reaching the United States, according to the CDC.
18 March 2009 : Federal District of Mexico begins to pick up cases of swine flu.
Are there any other countries in central america reporting swine flu cases?
04/30/09. I am a research fellow at Vanderbilt University. I got sick last week 04/20/09 after a visit of my husband that lives in Mexico city and was sick during his visit and before the news about swine flu. I posted the progress about the flu that I got with the symptoms described for a common flu, headache, fever higher that 100, muscle pain, strong coughing, weakness, chills, nasal congestion, eyes and chest pain, sneezing and mucus production with yellow and a light green color. The cough and the chest congestion was strong I could not sleep for two days and the normal medicines used for normal cold were not enough to deal with this. After my visit to the doctor on Thursday 04/23/09, the medical report concludes that I had flu with a strong pharyngitis and they prescribed me Tussionex suspension. I continue feeling so weak and, I lost my voice totally and I was feeling a general discomfort for more than one week. I reported my case considering the connection with Mexico and the new swine flu. Monday 04/27/09 after US declares health emergency I went to the hospital to give a sample. At the beginning they reject take the sample because my illness was longer than 6 days, then they change their mind and took a sample from the nose (deeply sample) and send me home to rest and wait. After almost 3 days dealing with the remaining symptoms like cough, mucus production, some headache, lost of appetite, some nausea, weakness and dizziness. The result was provided personally that I have seasonal Flu but they did not give me a final medical report with the result and according to the Medical doctor they are doing a second analysis of the sample using RTPCR to be absolutely sure. Now I am under antibiotics for a subsequent infection. The only thing that I want add is that the results from the swine flu test took too much time, almost 3 days, also if you read the symptoms are quite similar between both flu viruses. Today 04/30/09 I was looking information about on NCBI and also I can notice that the sequence form H1N1 virus from Mexico is not available. The question is why the sequence is not there if today the level of pandemic according to CDC is level 5 and how they are classifying the people as positive or negative cases considering also that the symptoms between both viruses are almost the same.
Flu condition and status in Comal County Texas as of 30 April 2009 Subject: Flu Update from Dr. Gitterle By Bill Gast/freelance@addisongastbooks.com The following comes from a recent discussion between community officials and school officials just hours ago. Facts as we know at this hour; - The virus is infectious for about 2 days prior to symptom onset - Virus sheds more than 7 days after symptom onset (possibly as long as 9 days) (this is unusual) - Since it is such a novel (new) virus, there is no "herd immunity," so the "attack rate" is very high. This is the percentage of people who come down with a virus if exposed. Almost everyone who is exposed to this virus will become infected, though not all will be symptomatic. That is much higher than seasonal flu, which averages 10-15%. The "clinical attack rate" may be around 40-50%. This is the number of people who show symptoms. This is a huge number. It is hard to convey the seriousness of this. - The virulence (deadliness) of this virus is as bad here as in Mexico, and there are folks on ventilators here in the US, right now. This has not been in the media, but a 23 month old near here is fighting for his life, and a pregnant woman just south of San Antonio is fighting for her life. In Mexico, these folks might have died already, but here in the US, folks are getting Tamiflu or Relenza quickly, and we have ready access to ventilators. What this means is that within a couple of weeks, regional hospitals will likely become overwhelmed. - Some of the kids with positive cases in Comal County had more than 70 contacts before diagnosis. - There are 10-25 times more actual cases (not "possible" cases -- actual), than what is being reported in the media. The way they fudge on reporting this is that it takes 3 days to get the confirmatory nod from the CDC on a given viral culture, but based on epidemiological grounds, we know that there are more than 10 cases for each "confirmed" case right now. - During the night, we crossed the threshold for the definition of a WHO, Phase 6 global pandemic. This has not happened in any of our lifetimes so far. We are in uncharted territory. - I expect President Obama will declare an emergency sometime in the next 72-96 hours. This may not happen, but if it doesn't, I will be surprised. When this happens, all public gathering will be cancelled for 10 days. - I suggest all of us avoid public gatherings. Outdoor activities are not as likely to lead to infection. It is contained areas and close contact that are the biggest risk. - Tamiflu is running out. There is a national stockpile, but it will have to be carefully managed, as it is not enough to treat the likely number of infections when this is full-blown. I don't think there is a big supply of Relenza, but I do not know those numbers. If I had to choose, I would take Relenza, as I think it gets more drug to the affected tissue than Tamiflu. - You should avoid going to the ER if you think you have been exposed or are symptomatic. ER's south of here are becoming overwhelmed -- and I mean that -- already. It is coming in waves, but the waves are getting bigger.( Image of ER admission at Texas Medical Center San Marcos, Christus ER in New Braunfels) - It appears that this flu produces a distinctive "hoarseness" in many victims. The symptoms, in general, match other flu's; namely, sore throat, body aches, headache, cough, and fever. Some have all these symptoms, while others may have only one or two. Suggestions for prevention and treatment from a local Dr. the did not wish to be named; (1) N-Acetyl-Cysteine -- a nutritional supplement available at the health food store or local Pharmacy, has been shown to prevent or lessen the severity of influenza. I suggest 1200mg, twice a day for adults, and 600mg twice a day in kids=2 0over 12. It would be hard to get kids under 12 to take it, but you could try opening the capsules and putting it on yogurt. For 40 pounds and up, 300-600 mg twice a day, for less than 40 pounds, half that. (2.) Oscillococinum, a homeopathic remedy, has been vindicated as quite effective in a large clinical trial in Europe, with an H1N1 variant. 30
Swine Flue- Prevention ; vaccine; or drug? Epidemic , pneumonia and death--During March-2009, in the busiest Mexico city of, USA, saw unusual patterns of acute cases of respiratory infection [suspected cases of flu with severe pneumonia] admitted in city hospitals. Cases began to emerge in middle of March2009 and over 1840 people with pneumonia had been reported in that capital, Mexico City, and more then 150 healthy people of 20-40 years of age died out of that pneumonia. Other cases had been reported in San Luis Potosi, in central Mexico and near the US border in Mexicali. In United States,> 40 cases have been confirmed and cases had been confirmed also in Spain. Suspected cases are under investigation in the United Kingdom, Brazil, Israel, Australia and New Zealand and in India. The disease started with all the symptoms described for a normal seasonal Flu or an influenza flu, like severe headache, fever, higher that 100oF, muscle pain, strong coughing, weakness, chills, nasal congestion, chest pain, sneezing and mucus production with yellow and a light green color sputum- sign of pneumonia. On 18 April, a laboratory in the United States reported two human cases of swine flu?the result of a novel re assortment of influenza A strain H1N1 from avian, may be caused by the H5N1 ?avian flu? variant (CDC 2007) swine, and human strains?in two children from California. The first person outside of Mexico to die from the H1N1 virus had been also confirmed. Richard Besser, acting director of the Centers for Disease Control and Prevention, confirmed the victim was a 23-month old child. In Germany, the Robert Koch Institute has confirmed three cases. The institute is the country?s national reference centre for influenza. The virus (see 'The turbulent history of the A(H1N1) virus') had extended its range to 21 countries on 5 continents, with 1,124 confirmed cases and 26 deaths. A week later, on 25 April, the World Health Organization declared the swine flu outbreak in North America a "public health emergency of international concern." This decision, in accordance with the International Health Regulations, means that countries have been asked to step up reporting and surveillance of the deaths and illnesses associated with the disease. From 17 April to 26 April Swine flu continued to make headlines until the World Health Organization raised the pandemic threat alert to level 5 (out of 6) declared by wHO on April 29 2009. At this point the surveillance systems for Swine flu are relying on the case reports or what is called a passive surveillance. This does not exclude the possibility that the virus has been circulating and adapting to its new hosts (swine and humans)for some time with no symptoms or low pathogenicity active surveillance to be implemented. which means sampling both populations to detect antibodies and virus The Virus- This is influenza A virus. These viruses are classified on the basis of two surface proteins: haemagglutinin and neuraminidase. There are 15 known forms of haemagglutinin and 9 of neuraminidase. The haemagglutinin type gives the H number and the neuraminidase type the N number. The Mexican flu appears to be a new virus. The viruses contain genetic pieces from four different virus sources. These genetic pieces are from North American swine influenza viruses, North American avian influenza viruses, human influenza viruses and swine influenza viruses found in Asia and Europe. A previous outbreak of H1N1 swine flu occurred in 1976 and claimed the life of a soldier at Fort Dix in the United States, but did not spread further. A number of people also developed Guillain-Barré syndrome from a rapidly implemented nation-wide vaccination programme. Transmissions -; Influenza viruses are reasonably common in pigs. Traditionally, most human cases of swine flu are contracted through contact with infected animals, rather than from human-to-human transmission but this flu does seem to be spreading between people. It spreads in the same way as normal flu, with most of those infected likely to have contracted it through airborne viruses. Infection by touching contaminated surfaces is also possible. Symptoms are also likely to resemble those of normal flu. .Treatment; Prevention- Transmission of some (e.g. influenza) viruses is predominantly spread by aerosol droplets, of others (e.g. SARS) by close personal contact, and others (e.g. respiratory syncytial virus; RSV) by fomites, with varying degrees of overlap between the modes of spread of respiratory viruses into the community and the spread can be prevented by intervening with hygienic measures aimed towards younger children and olds. Hand washing more than several times, daily wearing masks ,wearing gloves, wearing gowns and hand washing, masks, gloves, and gowns combined. The incremental effect of adding virucidals or antiseptics to normal hand washing to decrease the spread of respiratory disease. The United States Centers for Disease Control and Prevention (CDC) recently issued guidelines for use of facemasks in preparation for an influenza pandemic, such as that may be caused by the H5N1 ?avian flu? variant (CDC 2007). In the guidance document, the use of surgical facemasks by healthcare workers is recommended when respirators (such as the N-95) are not available [2] Adults can shed influenza virus one day before their symptoms appear and can sheds up to five days after onset of illness; thus, the selective use of masks (e.g., in proximity to a known symptomatic person) may not effectively limit transmission in the community. Instead, emphasis should be placed on cough etiquette.[2] In a pandemic situation, perhaps all healthcare workers should also wear facemasks whenever they are in contact with patients, and not just in the presence of ?confirmed or suspected pandemic influenza .With the outbreak of SARS in early 2003, and the recent emergence of the H5N1 `avian flu` as a high-mortality variant capable of human infection, the concern over respiratory spread of disease has greatly heightened among the public and among healthcare workers [3,4]. However, there is no evidence that these types of masks are effective in protecting healthcare workers from SARS [5.] The use of masks by healthcare workers in Japan in particular, and in Asia in general, has been ascribed in part to the desire to decrease the risk of respiratory infection from or to patients. Anti-viral drugs are of questionable efficacy with some dangerous side effects like the ones reported in Japan People are abusing of the regular flu vaccination, which is not useful for swine flu using oseltamivir (Tamiflu) and zanamivir (Relenza) against people diagnosed with the virus. However Mexico City are using oseltamivir (Tamiflu) and zanamivir (Relenza) against people diagnosed with the virus. During the 2004?2007 influenza seasons, median age of the children who died was 5 years. Children were said to progress rapidly to death; 45% died within 72 hours of onset. Staphylococcus aureus isolated from endotracheal tubes was said to be resistant to treatment in 64%. Children with co-infection were significantly older and more likely to have pneumonia and acute respiratory distress syndrome than those who were not co-infected (1). we must take adequate care to prevent introducing bacteria when performing practical procedures. If H5N1 or muted virus start spreading from developing nations combined with this Antibiotic Resistant Bacterial infection, these bacteria will soon bring an end to our profession. Nice guideline[7] Oseltamivir and zanamivir are recommended as possible treatments for people with flu if all of the following apply:*the person is in an 'at-risk' group **the person has a 'flu-like illness' and can start treatment within 48 hours (36 hours for zanamivir treatment in children) of the first sign of symptoms. ***the flu virus is known to be going around and it is likely that a flulike illness has been caused by the flu virus ****The guidance does not cover widespread epidemics.NICE has said that its recommendations about oseltamivir and zanamivir should not reduce efforts to give vaccination. The cost of drugs is very high £40 to £66 for oseltamivir and zanamivirr and I myself is strongly against the use of these drugs except for tightly defined at risk groups. These drugs are not for healthy people Vaccination- There is no vaccine available now. The U.S. Centers for Disease Control and Prevention (CDC) claims that ?the single best way to prevent seasonal flu is to get vaccinated each year[6] Is this possible? Numerous reviews have shown that the benefits of influenza vaccination have been overstated--most importantly in the elderly population; the very group most needing protection2Such confidence in influenza vaccines seems misplaced for two reasons. First, if CDC viral surveillance data is correct, then in recent years true influenza viruses have only caused an average of 12% of influenza-like illness Some other measures may be considered also[8] a mixed bag of advice by BM hedge published in BMJ blogs to boost up immune system during H1N1 epidemic. Good exercise daily*. Plenty of fruits and vegetable diet. *Drinking plenty of water. Adequate sleep at night. *Avoiding undue panic. *Mother?s milk gives the baby robust immune system. *Smoking and alcohol could be avoided during the epidemic. *Avoid crowded places and unnecessary travel to reduce the viral load. *Frequent hand washing and using a face mask might help References-: 1] Kadiyali Srivatsa Antibiotic Resistant Secondry Bacterial Infection And Swine Flu5 May 2009Rapid Responses to: EDITORIALS:Richard Coker Swine flu BMJ 2009; 338: b1791 2] Offie C. Wortham Joshua L. Jacob sOsamu Takahashi, Sachiko Hirai, Yasuharu Tokuda, Fumio Omata, and Tsuguya Fukui Re: When fear trumps science: a case study for finding alternative research methods 14 February 2009 Rapid Responses to: RESEARCH:Tom Jefferson, Ruth Foxlee, Chris Del Mar, Liz Dooley, Eliana Ferroni, Bill Hewak, Adi Prabhala, Sree Nair, and Alex Rivetti Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review BMJ 2008; 336: 77-80 3] Lau JT, Yang X, Tsui HY, Pang E. SARS related preventive and risk behaviours practised by Hong Kong-mainland China cross border travellers during the outbreak of the SARS epidemic in Hong Kong. J Epidemiol Community Health. 2004 Dec;58(12):988-96. 4]Lau JT, Kim JH, Tsui H, Griffiths S. Perceptions related to human avian influenza and their associations with anticipated psychological and behavioral responses at the onset of outbreak in the Hong Kong Chinese general population. Am J Infect Control. 2007 Feb;35(1):38-49 5] Derrick JL, Gomersall CD.?Protecting healthcare staff from severe acute respiratory syndro me: filtration?capacity of multiple surgical masks. J Hosp Infect. 2005 Apr;59(4):365-8 6]Centers for Disease Control and Prevention. ?Preventing Seasonal Flu? http://www.cdc.gov/flu/protect/preventing.htm Retrieved Nov 10, 2007. 7)Influenza - zanamivir, amantadine and oseltamivir NICE guide line Guidance type: Date issued: February 2009 Technology appraisal Reference: TA168 8] B M Hegde on flu? BMJ Group Blogs 30 Apr, 09 | by Juliet walker posted in guest bloggers Professor Pranab Kumar Bhattacharya, Professor of Pathology, Institute of Post Graduate Medical Education & Research-244a AJC bose Road, Kol-20, India