EuroFlu - Weekly Electronic Bulletin
Week 44 : 26/10/2009-01/11/2009 06 November 2009, Issue No. 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 Children’s 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 5–14 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 2004–2008). 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.

Map

The map presents the qualitative indicators of influenza activity (intensity, trend, geographical spread and impact) and the dominant virus as assessed by each of the countries.

Clicking on the map will, if available, take you through to the national web site. If 'regional' activity is reported, a pop-up text box will appear which describes the activity in greater detail.

Clicking on France, Russian Federation, Turkey and United Kingdom (England) will provide you with regional data.

Northern Ireland Iceland Denmark Norway Norway Sweden Sweden Denmark Scotland Scotland Finland Sweden England England England England Wales Ireland The Netherlands Belgium France France Switzerland Germany Germany Bulgaria Czech Republic Slovakia Slovenia Poland Poland Hungary France Italy Italy Italy Italy Italy Spain Spain Spain Spain Spain Portugal Portugal (Azores) Greece Estonia Albania FYROM Turkey Turkey Finland Finland Finland Romania Romania Malta Cyprus Austria Croatia Boznia and Herzegovina Montenegro Serbia Lithuania Luxembourg Latvia Denmark Norway
Type of map :   Intensity + virological          Geographical spread + virological          Impact
Europe Year 2009 / Week 44


A = Dominant virus A
H1N1 = Dominant virus A(H1N1)
H3N2 = Dominant virus A(H3N2)
H1N2 = Dominant virus A(H1N2)
B = Dominant virus B
A & B = Dominant virus A & B

= : stable clinical activity
+ : increasing clinical activity
- : decreasing clinical activity

Low = no influenza activity or influenza at baseline levels
Medium = usual levels of influenza activity
High = higher than usual levels of influenza activity
Very high = particularly severe levels of influenza activity

No activity = no laboratory-confirmed case(s) of influenza, or evidence of increased or unusual respiratory disease activity.
Sporadic = isolated cases of laboratory confirmed influenza infection
Localized = limited to one administrative unit of the country (or reporting site) only.
Regional = appearing in multiple but <50% of the administrative units of the country (or reporting sites).
Widespread = appearing in ≥50% of the administrative units of the country (or reporting sites).

Country 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.
Table and graphs

Intensity Geographic
spread
Impact Trend Dominant
type
Sentinel
swabs
Percentage
positive
ILI per
100 000
ARI per
100 000
Virology graph
and pie chart
AlbaniaMediumSporadicModerateIncreasingType A, Subtype pH1442.3% (graphs)Click here
AustriaLowRegionalLowStableNone1717.7%1026.3 (graphs)Click here
AzerbaijanLowNoneLowStableNone380% (graphs)Click here
BelarusHighLocalIncreasing845.9 (graphs)Click here
BelgiumMediumWidespreadLowIncreasingType A, Subtype pH121874.8%811.9 (graphs)2077.6 (graphs)Click here
BulgariaHighRegionalIncreasingType A, Subtype pH11499.9 (graphs)Click here
CroatiaLowLocalLowIncreasing3.0 (graphs)Click here
Czech RepublicLowLocalStable35.7 (graphs)877.9 (graphs)Click here
DenmarkType A, Subtype pH1N12100.0% (graphs)Click here
EstoniaMediumSporadicLowIncreasingType A, Subtype pH1N11030.0%5.9 (graphs)260.7 (graphs)Click here
FranceMediumRegionalLowStable1864.1 (graphs)Click here
GeorgiaNone540% (graphs)Click here
GermanyLowRegionalLowIncreasingType A, Subtype pH1N115239.5%1213.1 (graphs)Click here
GreeceType A, Subtype pH1N1616.7% (graphs)Click here
HungaryLowSporadicLowDecreasingType A, Subtype pH1547.4% (graphs)Click here
IcelandVery HighWidespreadDecreasingNone19029.0%421.3 (graphs)Click here
IrelandVery HighWidespreadModerateStableType A, Subtype pH1N18057.5%178.5 (graphs)Click here
IsraelMediumWidespreadLowIncreasingType A, Subtype pH1117.1 (graphs)Click here
ItalyHighWidespreadIncreasingType A, Subtype pH1N1425.0%896.3 (graphs)Click here
KazakhstanMediumLocalModerateIncreasingNone (graphs)Click here
KyrgyzstanNone00% (graphs)Click here
LatviaLowSporadicStableType A, Subtype pH110% (graphs)911.8 (graphs)Click here
LithuaniaLowSporadicLowIncreasingNone250.0% (graphs)Click here
NetherlandsHighWidespreadLowIncreasingType A, Subtype pH17941.8%117.7 (graphs)Click here
NorwayHighWidespreadModerateIncreasingType A, Subtype pH1N16645.5%439.4 (graphs)Click here
PolandLowSporadicLowIncreasingNone2821.4%92.1 (graphs)Click here
PortugalMediumSporadicLowIncreasingType A, Subtype pH11758.8%56.5 (graphs)Click here
Republic of MoldovaMediumSporadicIncreasingType A, Subtype pH11942.1%0.9 (graphs)198.5 (graphs)Click here
RomaniaMediumLocalModerateIncreasingType A, Subtype pH114036.4%1.8 (graphs)904.2 (graphs)Click here
Russian FederationHighWidespreadIncreasingType A, Subtype pH11070.7 (graphs)Click here
SerbiaMediumRegionalIncreasingType A, Subtype pH100%108.6 (graphs)Click here
SlovakiaLowLocalLowIncreasingType A, Subtype pH1785.7%248.7 (graphs)1729.9 (graphs)Click here
SloveniaLowSporadicStableType A, Subtype pH11827.8%4.9 (graphs)915.8 (graphs)Click here
SpainMediumWidespreadIncreasingType A, Subtype pH1N176160.8%292.0 (graphs)Click here
SwedenHighWidespreadModerateIncreasingType A, Subtype pH114243.0%17.5 (graphs)Click here
SwitzerlandMediumLocalLowStableType A, Subtype pH13417.7%35.4 (graphs)Click here
United Kingdom - EnglandMediumWidespreadStableType A, Subtype pH1N143933.7%37.7 (graphs)429.3 (graphs)Click here
United Kingdom - Northern IrelandHighSporadicStableType A, Subtype H1N14185.4%222.1 (graphs)Click here
United Kingdom - ScotlandMediumRegionalStable45.6 (graphs)Click here
United Kingdom - WalesMediumWidespreadModerateDecreasingType A, Subtype pH12339.1%59.0 (graphs)Click here
UkraineMediumRegionalSevereIncreasingType A, Subtype pH11643.8%762.3 (graphs)Click here
UzbekistanLowNoneLowIncreasingNone283.6%34.0 (graphs)Click here
Europe273044.7% Click here
Preliminary data

Intensity: Low = no influenza activity or influenza activity at baseline level; Medium = usual levels of influenza activity; High = higher than usual levels of influenza activity; Very high = particularly severe levels of influenza activity.
Geographical spread: No activity = no laboratory-confirmed cases, or evidence of increased or unusual respiratory disease activity; Sporadic = isolated cases of laboratory-confirmed influenza infection; Localized = limited to one administrative unit in the country (or reporting site) only; Regional = appearing in multiple but <50% of the administrative units of the country (or reporting sites); Widespread = appearing in >=50% of the administrative units of the country (or reporting sites).
Impact: Low = demands on health-care services are not above usual levels; Moderate = demands on health-care services are above the usual demand levels but still below the maximum capacity of those services; Severe = demands on health care services exceed the capacity of those services.
Trend: Increasing = evidence that the level of respiratory disease activity is increasing compared with the previous week; Stable = evidence that the level of respiratory disease activity is unchanged compared with the previous week; Decreasing = evidence that the level of respiratory disease activity is decreasing compared with the previous week.
Dominant type: this assessment is based on data from sentinel and non-sentinel sources.
Sentinel swabs (% pos.): number of sentinels swabs tested for influenza and percentage that tested positive for influenza A or B.
ILI: influenza-like illness.
ARI: acute respiratory infection.
Sentinel SARI: severe acute respiratory illness.
Population: per 100 000 population.
* The value in the table for these countries reflects the percentage (e.g. from 0.0 to 100.0) of total outpatient encounters that were due to ILI/ARI rather than a consultation rate per 100 000 population.
- Not applicable.

The bulletin text was written by an editorial team at the WHO Regional Office for Europe (Caroline Brown and Joshua Mott), the Netherlands Institute for Health Services Research (NIVEL; John Paget and Tamara Meerhoff, Temporary Advisers to WHO) and the WHO Collaborating Centre for reference and research on influenza, Mill Hill, United Kingdom (Rod Daniels). The bulletin was reviewed by Douglas Fleming (Royal College of General Practitioners, United Kingdom), Lars Nielsen (Statens Serum Institute, Denmark) and Anne Mosnier (Open Rome, France) on behalf of the data contributors.

© World Health Organization 2013. All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization or its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its partners be liable for damages arising from its use.
EuroFlu : Weekly Electronic Bulletin