2009 flu pandemic by country

This article deals with the status and efforts regarding the 2009 flu pandemic by country and continent/region.

2009 flu pandemic - Cases by country

Pandemic (H1N1) 2009–2010 by country
Summary of official reports.^‡‡

Country	Indicators/					Cases	Deaths
	Spread-Trend/ Intensity/Impact‡					Confirmed‡‡	Confirmed
ECDC total[1]							14,378
Reports Total						1,632,258	19,633
United States^	W	=	**	mod	[2]	(113,690)[3]	3,433[4]
Brazil	R	-	*	mod	[2]	(58,178)[5]	2,135[6]
India	W	+	*	low	[7]	29,599[8]	2,024[8]
Mexico	W	+	**	mod	[9]	70,715[10]	1,316[10]
China (mainland)						120,940[11]	800[12]
Turkey	R	+	**	mod	[13]	12,316[14]	656[15]
Argentina	W	-		low	[16]	(11,458)[16]	626[17]
Russia	W	+	**		[18] [19]	25,339[20]	604[21]
United Kingdom#	R	=	*		[22] [23]	(28,456)[24]	474[25]
Canada	W	+	**		[2]	(25,828)[26]	429[27]
France~	R	=	*	low	[13]	5,000[28][29]	344[30]
Spain	W	+	*		[13]	(1,538)[31]	300[32]
Egypt						15,812[33]	278[34]
Germany	N	=		low	[35]	(222,360)[36]	258[37]
South Korea	W	+	*	low		107,939[38]	250[39]
Thailand	R	=	*	low	[7]	31,902[40]	249[41]
Italy	W	+	**		[42]	3,333[43]	244[44]
Colombia	W	+	*	mod	[2]	152,560[45]	243[46]
Peru	W	-	*	low	[9]	9,165[47]	223[17]
Ukraine	R	+	**	mod	[13]	494[48]	213[48]
Ecuador	W	-	*	low	[2]	2,251[47]	200[49]
Japan	W	+			[50]	11,636[51]	198[52]
Australia	W	-			[53]	37,484[29]	193[54]
Poland	W	+	**	mod	[13]	(2,024)[55]	181[56]
Chile	W	=		low2	[57]	12,258[58]	156[59]
Syria						(452)[60]	152[60]
Greece	N	+	*		[13]	(17,977)[61]	149[62]
Iran						3,672[63]	147[1]
Venezuela	W	-	*	mod	[2]	2,187[64]	135[65]
Hungary	L	+		low	[13]	(283)[66]	134[67]
Saudi Arabia						14,500[63]	128[63]
Portugal	R	+	*	low	[68]	(166,922)[69]	122[70]
Romania	W	+	*	mod	[13]	6,999[71]	122[72]
Czech Republic	L	+			[13]	2,445[73]	102[74]
Israel	W	+	*	low	[13]	4,330[75]	94[76]
South Africa						12,640[77]	93[1]
Malaysia						12,210[78]	92[79]
Belarus	W	+	**	mod	[13]	102[80]	88[81]
Serbia	R	+	**	low	[13]	695[82]	83[83]
Hong Kong						33,109[84]	80[85]
Cuba	W	+	**	mod	[86]	973[87]	69[88]
Costa Rica	W	-	*	low	[2]	(1,867)[89]	67[90]
Morocco						2,890[63]	64[63]
Netherlands+	W	+	*	low	[13]	(1,473)[91]	62[92]
Bolivia	W	-	*	low	[2]	2,310[47]	59[1]
Vietnam						11,186[93]	58[94]
Algeria						916[77]	57[1]
Finland	W	+	**		[13]	6,122[95]	56[96]
Slovakia	S	+		low	[13]	955[97]	56[98]
Paraguay	L	-	**		[2]	855[47]	54[1][99]
New Zealand	L	=	*	low	[22]	(3,199)[29]	50[100][101]
Taiwan						(5,474)[102]	48[103]
Sri Lanka	W	+	*	low	[7]	642[40]	48[40]
Moldova						2,524[104]	46[105]
Palestinian Territories						1,676[63]	43[63]
Iraq						2,880[63]	42[1]
Austria	W	+		low	[13]	(964)[106]	40[107]
Bulgaria	W	+	***		[13]	766[108]	40[109]
Countries with < 40 deaths Country Indicators ‡ Confirmed cases Deaths Latvia S + low [68] 1,253[110] 34[111] Oman 6,349[112] 33[113] Georgia L + * low [13] 1,300[114] 33[115] El Salvador R = * low [2] 834[116] 33[17] Denmark W + * [13] (651)[91] 33[117] Uruguay W - * low [118] (550)[47] 33[1] Philippines W - [119] 5,212[120] 32[121] Yemen 5,038[122] 31[63] Kuwait 8,669[123] 30[1] Mongolia 1,259[124] 30[125] Norway W - * low [13] (12,654)[126][1] 29[1] Sweden W + *** mod [13] (10,985)[127] 29[128] Ireland W = *** mod [13] (3,189)[129] 26[130] Macedonia N - [131] (2,600)[132] 26[133] Croatia W + low [13] (526)[134] 26[1] Pakistan 253[135] 25[136] Tunisia 1,200[63] 24[63] Guatemala N - * low [2] 1,170[47] 24[137] Dominican Republic R + ** mod [2] 491[47] 23[1] Lithuania S + low [13] 68[138] 23[139] Singapore (1,217)[140] 21[141] Estonia L + * mod [13] (738)[142] 21[143] Belgium W - * low [13] 76,973 [144][145] 19[146] Jordan 3,033[147] 19[1] Slovenia L + * [13] (990)[148] 19[149] Switzerland W + * low [13] 11,221[150] 18[151] Honduras W - * low [152] 560[47] 18[153] Afghanistan 853[154] 17[1] Kosovo 98[155] 14[1] Bosnia and Herzegovina L [156] 714[157] 13[158] Panama W - * low [159] 813[160] 12[17] Albania S + * mod [42] 426[161] 12[162] Nicaragua W - * low [2] 2,172[47] 11[17] Indonesia R = * mod [163] 1,098[40] 10[1] Qatar 550[164] 10[1] Cyprus N [13] (297)[91] 10[165] North Korea 28[40] 10[166][167] Bahrain 1,325[63] 8[63] Mauritius (69)[77] 8[1] Bangladesh R - * low [7] 1,015[40] 7[40] Jamaica W + * low [168] 191[169] 7[1] Montenegro N [170] 119[171] 7[1] Cambodia R + * [50] 531[172] 6[1] United Arab Emirates 125[173] 6[1] Lebanon 1,838[63] 5[1] Malta R + ** [174] (718)[175] 5[176] Trinidad and Tobago W = * low [177] 211[47] 5[1] Sudan 145[178] 5[1] Bahamas W + * mod [179] 29[173] 4[1] Madagascar 877[77] 3[1] Ghana 676[77] 3[180] Luxembourg W + ** low [174] 333[91] 3[1] Nepal R + * low [7] 172[40] 3[40] Barbados W - * low [159] 154[47] 3[1] Armenia 119[181] 3[1] Iceland W - *** [13] 8,650 [182][175] 2[1] Macau (PRC) 2,625[84] 2[1] Brunei W - * mod [183] 971[184] 2[185] Samoa 138[29] 2[1] Suriname N = * low [159] 110[186] 2[1] São Tomé and Príncipe 66[77] 2[1] Mozambique 57[77] 2[1] Nigeria 11[77] 2[77] St. Kitts and Nevis N = * low [187] 6[47] 2[1] Tanzania 770[77] 1[1] Libya 764[63] 1[1] Laos 242[188] 1[1] Cayman Islands (UK) 121[24] 1[1] Marshall Islands 115[29] 1[1] Cook Islands (NZ) 106[29] 1[1] Namibia 75[77] 1[1] St. Lucia W - * mod [2] 55[47] 1[1] Maldives L - low [7] 35[40] 1[1] Bermuda (UK) 25[189] 1[1] Tonga 20[29] 1[1] Falkland Islands (UK) 7[24] 1[24] Solomon Islands 4[29] 1[1] Other 7,052 0 Countries with no deaths Country Indicators ‡ Confirmed cases Deaths Zimbabwe 1,318[190] 0 Zambia 726[191] 0 Jersey (UK) 702[192] 0 Rwanda 482[77] 0 Kenya 417[77] 0 Senegal 325[77] 0 Uganda 263[77] 0 Fiji N - * low [22] 234[29] 0 Democratic Republic of the Congo 222[77] 0 Myanmar L - low [7] 137[40] 0 Cape Verde 118[77] 0 Akrotiri and Dhekelia (UK) 92[24] 0 Bhutan N [7] 91[193] 0 Haiti L + low [194] 91[47] 0 Micronesia 82[29] 0 Antigua and Barbuda R = * low [195] 75[47] 0 Isle of Man (UK) 75[24] 0 Lesotho 65[77] 0 Gibraltar (UK) 62[24] 0 Kyrgyzstan N = low [196] 61[197] 0 Belize W - mod [86] 49[198] 0 Niger 49[77] 0 Palau 47[29] 0 Faroe Islands 44[199] 0 Turks and Caicos Islands (UK) 44[24] 0 Angola 37[77] 0 Dominica N = * low [200] 36[47] 0 Monaco 36[201] 0 Seychelles 33[77] 0 Botswana 31[202] 0 Mali 29[77] 0 Guyana 27[203] 0 British Virgin Islands (UK) 25[24] 0 Tuvalu 23[29] 0 Montserrat 21[24] 0 Republic of the Congo 21[77] 0 Grenada W - * mod [2] 20[47] 0 Ethiopia 19[77] 0 Guernsey (UK) 17[24] 0 Kazakhstan R + ** mod [13] 17[173] 0 St. Vincent and the Grenadines L = [204] 17[47] 0 Tajikistan 16[205] 0 Mauritania 15[77] 0 Anguilla (UK) 14[24] 0 Azerbaijan L + * low [13] 14[206] 0 Papua New Guinea 12[29] 0 Côte d'Ivoire 9[77] 0 Djibouti 9[63] 0 Nauru 8[29] 0 Burundi 7[77] 0 Timor-Leste L = low [207] 7[40] 0 Liechtenstein 5[91] 0 San Marino 5[208] 0 Swaziland 5[209] 0 Cameroon 4[77] 0 Gabon 4[77] 0 Kiribati 4[29] 0 Guinea 3[77] 0 Vanuatu 3[29] 0 Somalia 2[63] 0 Andorra 1[173] 0 Chad 1[77] 0 Greenland 1[210] 0 Graph of confirmed cases Semi-logarithmic plot of laboratory-confirmed A(H1N1) influenza cases in 2009 according to WHO reports.[211] ‡Qualitative indicators as defined by WHO[212]. Parameter values: Geographic spread Trend Intensity Impact on health care services W(idespread) *** (very high) sev(ere) R(egional) + (Increasing) ** (high) mod(erate) L(ocal) = (Unchanged) * (low - moderate) S(poradic) I(mported) N(o activity) - (Decreasing)   (low) low ‡‡Many countries are not recommending laboratory tests for all suspect cases, the affected numbers have been put in brackets. Comparisons in time or between these countries should not be made. The number of confirmed cases is lower than the total number of cases,[213] and may grossly underestimate the true infection rate.[214] ^Includes Puerto Rico (695 cases, 45 deaths), Guam (338 cases, 2 deaths), American Samoa (85 cases, 1 death), U.S. Virgin Islands (80 cases, 1 death), and Northern Mariana Islands (6 cases). #Does not include Overseas Territories or Crown Dependencies. ~Includes New Caledonia (500 cases, 9 deaths), French Polynesia (183 cases, 7 deaths), Réunion (759 cases, 7 deaths), Mayotte (164 cases, 2 deaths), Martinique (261 cases, 1 death), French Guiana (213 cases, 1 death), Guadeloupe (197 cases, 5 deaths), Saint-Martin (62 cases), Wallis and Futuna (55 cases), Saint-Barthélemy (2 cases). +Includes Aruba (13 cases) and the Netherlands Antilles (98 cases).

     Confirmed cases followed by death      Confirmed cases      Unconfirmed or suspected cases See also: H1N1 live map, WHO updates

     0 deaths      suspected deaths      1+ deaths      5+ deaths      10+ deaths      50+ deaths      100+ deaths      500+ deaths See also: H1N1 live map, WHO updates

     Confirmed community outbreaks See also: H1N1 live map, WHO updates

     Confirmed mutation of H1N1 virus

     Confirmed double infections

     Confirmed cases of tamiflu resistance

Overview

As the pandemic progresses, laboratory testing and confirmation may decrease. Confirmed figures for the United Kingdom, in particular, are only meaningful up to 2 July 2009, when routine testing stopped and presumed cases were treated without laboratory confirmation of diagnosis. Following the recommendations of the World Health Organization (WHO), many countries stopped issuing the numbers of the infected population, making this list inaccurate.

The ten countries and territories with most confirmed cases per capita

Pos.	Country	Population[nb 1]	Confirmed cases	Confirmed cases per 1,000 inhabitants
1	Iceland	306,694	8,650	28.20
2	Portugal	10,707,924	166,922	15.59
-	Cook Islands	11,870	106	8.93
3	Belgium	10,414,336	214,531[215]	20.59
-	Macau	559,846	2,625	4.68
-	Hong Kong	7,055,071	31,554	4.47
4	Spain	46,700,000	(155,051)	3.32
5	Kuwait	2,691,158	8,622	3.20
6	Brunei	338,190	972	2.87
-	Jersey	91,626	234	2.55
7	Germany	82,080,000	(192,348)	2.34
8	South Korea	48,600,000	107,939	2.22
9	Palau	20,796	46	2.21
-	Cayman Islands	49,035	105	2.14
10	Malta	405,165	718	1.77
	World	6,790,062,216	25,584,595	3.76

*Includes countries with over 40 confirmed cases only.

Affected continents/countries

Africa

2009 flu pandemic in Africa:      Confirmed deaths     Confirmed cases     Suspect cases     No reported cases

No deaths     1+ deaths     5+ deaths     10+ deaths     50+ deaths     100+ deaths

The Egyptian government ordered the mass slaughter of all pigs in Egypt on April 29,^[216] even though the current strain is a human-human transmittable, human influenza that has already previously hybridized with avian and swine flu.^[217] The World Organization for Animal Health called the swine killing "scientifically unjustified".^[217]

The first case of the novel H1N1 virus was discovered in Cairo, Egypt on June 2, 2009, in a 12-year-old girl coming from the USA with her mother. Only the girl was infected, and the officials caught the case before getting out of the airport. A second and third case were discovered on Sunday 7 June 2009, 2 students at the American University of Cairo.^[218]

On June 11, 2 more cases were discovered, bringing the total number of swine flu cases to 12 in Egypt.^[219]

The swine flu has been confirmed in 21 African countries: Egypt, South Africa, Morocco, Algeria, Tunisia, Ethiopia, Ivory Coast, Seychelles, Cape Verde, Libya, Kenya,^[220] Uganda, Botswana, Zimbabwe, Tanzania, Mauritius, Somalia, Sudan, Namibia, Zambia, Gabon, and Rwanda.

The H1N1 virus was a concern in the months leading up to the 2010 FIFA World Cup, which took place in June 2010 in South Africa.^[221][222]

Asia

2009 flu pandemic in Asia      Deaths     Confirmed cases     Suspected cases     No reported cases

No deaths     1+ deaths     5+ deaths     10+ deaths     50+ deaths     100+ deaths

Western and Central Asia

H1N1 in Central Asia     Deaths     Confirmed cases     Suspected cases     No reported cases

H1N1 in Southwest Asia     Deaths     Confirmed cases     Suspected cases     No reported cases

On April 27, Azerbaijan imposed a ban on import of animal husbandry products from America.^[223] AZAL took additional safety measures and a sanitary quarantine unit of the Health Ministry started to operate in Heydar Aliyev International Airport with all aircraft and passengers being checked.^[224] On May 2 all checkpoints on borders with Russia passed to the medium security and disinfection barriers for both cars and pedestrians were installed at the Samur, Shirvanovka and Khan Oba checkpoints in Qusar and Khachmaz Raions.^[225] The veterinary services at checkpoints intensified their activities while hog farms in the northern regions passed to the closed farming regime.^[225]

Seventy-seven cases have been confirmed in Israel.^[226] In response to the outbreak, the Israeli Deputy Minister of Health, Yaakov Litzman, suggested out of respect for the religious sensibilities of Jews and Muslims, the flu should be called "Mexican Flu." This was done so as to not confuse the population into thinking that they could not acquire the virus if they did not eat pork.^[227][228] The Israeli government retracted this proposal following Mexican complaints.^[229]

The first confirmed cases of swine flu in Kuwait were reported on May 23, after about 18 people on U.S. military bases tested positive.^[230]

On May 30, 2009 three cases of swine flu were confirmed in Lebanon, the first in the country. "One Lebanese man who was in Spain and two Canadians who arrived in Lebanon a week ago are suffering from swine flu," the health minister said. "We put them in quarantine and the blood samples we have taken every day have proven to be positive. The Lebanese man and the two visiting Canadians -- a woman and her daughter -- were given the proper medical treatment in time and they are well now." The Lebanese Health Minister had previously asked citizens to stop the social habit of kissing. He also requested that affected schoolchildren be kept at home and that travel to countries in which cases have been confirmed be avoided.^[231] Beirut also banned the import of pork.^[232]

In Saudi Arabia, the first case of swine flu, which affected a Filipino nurse working at King Faisal Specialist Hospital and Research Center, was confirmed on June 1. The Health Ministry in cooperation with King Faisal Specialist Hospital and Research Center has applied the national plan for the prevention of Swine Flu in a manner that matches with the recommendations of WHO. Accordingly, the patient was isolated and provided with the required medical treatment. Arrangements are underway to examine those who were in contact with the patient to get sure that they are not infected.^[233] Saudi Arabia also took precautions and have currently closed all ISG (International Schools Group) schools after the eid holiday. In case they went back to their home country and contracted the virus. Schools willbe closed till at least October 10.

Southern Asia

H1N1 in South Asia     Deaths     Confirmed cases     Suspected cases     No reported cases

H1N1 in Southeast Asia     Deaths     Confirmed cases     Suspected cases     No reported cases

All people entering India via the main airport hubs of Mumbai, New Delhi, Kolkata, Ahmedabad, Goa, Jaipur, Kochi, Chennai, Bangalore and Hyderabad are being screened. The primary focus is on passengers entering from the United States of America, The United Kingdom, Canada, Mexico, France, and New Zealand.^[234] As of 25 October 2009, over 13000 cases have been confirmed in India with 444 deaths, starting with a 13-yr old girl's death in the city of Pune, where almost 91 people died in the city.^[235]

In the Maldives, a ministerial committee has been established to supervise swine flu preventive measures to avoid an outbreak. All visitors arriving at the Malé International Airport on Hulhule Island and the country's three commercial seaports are being screened.^[236]

Pakistan has taken precautionary measures at the international airports to check passengers coming from swine flu affected countries.^[237] Doctors are checking the incoming passengers and allow entry only to those with no flu symptoms. The major hospitals in all the big cities are on high alert.

Southeastern Asia

Since 8 July 2009 a total of 207 cases of A(H1N1) flu have been reported in Brunei.^[238]

Cambodia's health authorities remain alert but confident that the country is prepared for a swine flu pandemic. In terms of ensuring that infected pigs do not spread the disease to Cambodia, the Cambodian Pig Raiser Association said it has told the government it should ban live pig imports. But Khlauk Chuon, the deputy director of Camcontrol at the Ministry of Commerce, said they would only ban live pig imports from a country that has been hit with swine flu.^[239]

The Indonesian government halted the importation of pigs and initiated the examination of 9 million pigs in Indonesia.^[240] Thermal scanners which can detect human body temperature have been installed at Indonesian ports of entry.^[241]

The Lao government bought 10 thermal imaging machines to install at the country's major immigration border checkpoints. The Prime Minister Bouasone Bouphavanh said masks should be made available and health officials would be assigned to work at border checkpoints.^[242] On 22 July, Laos recorded its first death from influenza A(H1N1).^[243]

In Malaysia, health screenings were carried out on passengers traveling to and from Mexico via sea, air and land beginning April 17.^[244][245] The Health Ministry's disease control division activated its operations room to monitor the swine flu situation and informed medical practitioners treating suspicious cases to inform the district health office immediately.^[246] Thermal scanners were installed at Kuala Lumpur International Airport.^[247] Screenings were imposed in Pengkalan Hulu, at the border with Thailand, in late April.^[248] Quarantine rooms had been allocated in 28 hospitals,^[249] and the country has stockpiled more than 2 million doses of Tamilflu, as of May 2009.^[250] Schools were issued strict hygiene procedures on May 16 to contain any H1N1 outbreak among students and teachers.^[251] On May 15, the Health Ministry confirmed Malaysia's first case of A (H1N1) infection of a male student who had arrived via air from Newark.^{[245][247][252][253]} The first A(H1N1) related death was reported on 23 July 2009.^[254] As of August 11, 2009 there has been 2,253 confirmed cases in Malaysia.^[255] As of August 12, 2009 the total number of A(H1N1) related deaths in Malaysia stands at 44.^[256]

In Myanmar, Chairman of Global Human Flu Prevention and Response Work Committee Deputy Minister for Health Dr Mya Oo inspected preventive measures against the human flu at Yangon International Airport on May 1.

In the Philippines, thermal imaging equipment at airports was implemented to screen passengers coming from the US for flu symptoms.^[257][258] The Philippines may quarantine travelers arriving from Mexico with fevers.^[259] Also, the importation of hogs from the U.S. and Mexico was manned, and the restriction of swine influenza vaccine use was retracted.^[260] On May 18, 2009, a Filipina girl who arrived from Houston, USA was the first confirmed case of H1N1 virus in the Philippines.^[261] As of June 15, 2009, there were 193 confirmed cases.^[262] By June 22, first known death was reported.^[263]

The first case of Influenza A (H1N1-2009) in Singapore was confirmed on May 27, 2009. It was announced on June 18, 2009 that Singapore appeared to have its first case of local infection of the A(H1N1) virus.^[264] As of July 7 there have been reported 1,217 confirmed cases of A(H1N1) in Singapore.^[265] As of July 25, there were 4 confirmed deaths related to A(H1N1) virus in Singapore.^[266][267]

Vietnam's Ministry of Health released an emergency dispatch and urged agencies to take precautionary measures against swine flu.^[268] Thermal imaging devices were dispatched to airports and border gates to screen passengers.^[269] In response to WHO's warnings, Vietnam on April 30, 2009 raised its swine flu alert level to 4 which indicated a "threat of community level outbreaks" while local authorities have been executing precautionary measures.^[270] On May 1, 2009 an Vietnam's Ministry of Industry and Trade official said that Ministry was considering a ban on pork import "under certain situations" to prevent swine flu from entering Vietnam.^[271] As of May 31, 2009. The Government of Vietnam announced its First new case of A(H1N1) virus in the Country. A 23 years old Vietnamese student who recently returned from the United States has tested positive for swine flu.^[272]

Eastern Asia

H1N1 in Eastern Asia     Deaths     Confirmed cases     Suspected cases     No reported cases

On April 26, it was announced that visitors returning from flu-affected areas to China who experienced flu-like symptoms within two weeks would be quarantined.^[273] May 2, the Chinese government suspended flights from Tijuana to Shanghai.^[274] Meanwhile, the Civil Aviation Administration of China also assigned a charter to transport stranded Chinese visitors back home.^[275] The first suspected case found on mainland China was reported on May 10, 2009.^[276]

On April 29, 2009 the Food and Health Bureau of Hong Kong^[277] advised Hong Kong residents not to travel to Mexico unless absolutely necessary. The first case reported was a Mexican who flew in from Shanghai. The Bureau also escalated the alert level from "alert" to "serious",^[278] which activated health protection measures in all ports of entry of Hong Kong. As such, temperature screening machines are used at all checkpoints to identify passengers with fever and respiratory symptoms. Any passenger who fails the temperature test and confirmed having a fever will be quarantined and sent to public hospital for further investigation.^[279] Hong Kong also became one of the first jurisdictions to declare the swine flu as a notifiable disease, and much of the procedures against the spread of the swine flu were learned from the 2003 SARS outbreak, of which Hong Kong was the epicenter of the outbreak.^[280][281] On May 1, one case became the first confirmed case of swine flu in Hong Kong and also the first in Asia. The Mexican patient arrived in Hong Kong on April 30. Metropark Hotel Wanchai, where the patient stayed, was quarantined.^{[282][283][284][285]} After the first swine flu case was confirmed by laboratory, Hong Kong's response level was raised from "serious" to "emergency".^[286]

In Japan, any live pigs being brought into the country were inspected to ensure they were not infected with the influenza.^[287] Japanese Agriculture Minister Shigeru Ishiba appeared on television to reassure customers that it is safe to eat pork.^[288] The Japanese farm ministry said that it would not ask for restrictions on pork imports because the virus was unlikely to turn up in pork, and would be killed by cooking.^[289] On 8 May, the first three cases were confirmed. The infected patients had spent time in Canada and returned to Japan via Detroit.^[290][291] The first domestic infection was confirmed on 16 May in Kobe.^[292] As of 18 May, 130 cases had been confirmed.^[293]

South Korea warned against travel to Mexico City and three Mexican states.^[288] The government has also stepped up quarantine and safety checks on travelers arriving from the United States and Mexico, and pork imports from those countries. An emergency quarantine system is also in place, with simple tests conducted on people arriving with flu symptoms at airports.^[273] On April 28, South Korea reported its first probable case of swine flu after positive preliminary tests on a nun who had recently returned from a trip to Mexico.^[294] Several sources have informed that one case has been confirmed by lab in South Korea, on April 30.^[295][296] On May 2, the first suspected woman turned out to be infected with the influenza A subtype H1N1. South Korea became the second infected nation in Asia.^[297] On September 13, five people died, and 1 person got a brain death. As of November, 107,939 have been infected.^[298]

On May 20, 2009, the first case of the influenza has been confirmed in Taiwan^[299] The government had previously taken several steps to prevent the possible outbreak of Swine Flu, including a command center set up, travel alerts for infected nations,^[288] and more severe health check been conducted at international ports. Taiwan said visitors who came back from affected areas with fevers would be quarantined.^[300] According to The Department of Health (DOH), Taiwan has a sufficient supply of surgical masks and vaccine to deal with the flu. The DOH also stated that they have 50 million to 60 million masks in stock and local manufacturers have the capability of producing 200,000 doses of the flu vaccine a month.^[301] In an effort to prevent the entry of the swine influenza, the Centers for Disease Control has announced on April 28 that every flight from the Americas, specifically Canada and the United States, that arrives in Taiwan from April 29 and onward will be subject to a strict on-board screening procedure.^[302]

On July 2, the first case of oseltamivir-resistant virus in Asia was announced in Japan, in a woman who had been taking Tamiflu prophylacticly.^[303]

On July 18, 2009, Hong Kong had its first swine flu death.

On July 3, a case of Tamiflu-resistant virus was discovered in a woman suffering from the flu. The woman had not previously taken Tamiflu, so concern has been expressed that she may have contracted an already resistant virus from someone else.^[304]

On 28 August 2009, the Japanese Ministry of Health, Labour and Welfare announced that it estimated approximately 760,000 people would be infected and 46,400 hospitalized per day during the expected peak time of October 2009. Overall they predict 20% of rural Japanese to become infected and 30% in city areas.^[305]

Europe

Outbreak evolution in Europe:
     Deaths     Confirmed cases     Suspect cases     No cases

     No deaths     1+ deaths     5+ deaths     10+ deaths     50+ deaths     100+ deaths     500+ deaths     1000+ deaths     5000+ deaths

On April 27, the Spanish Ministry of Health and Social Policy announced that a man in Castilla-La Mancha who had recently returned from Mexico had contracted the disease. The man, aged 23, had returned from Mexico on April 22 and had been quarantined on the 25th. This was the first confirmed case in Europe.^[306]

On April 27, the European Union health commissioner advised Europeans not to travel to the United States or Mexico unless urgent. This followed the discovery of the first confirmed case in Spain.^[307]

On June 14, It was reported that the United Kingdom had its first confirmed swine flu related death. The individual was a Scottish woman named Diana Barnett.

As of December 22, every european country, apart from the 5 microstates have confirmed deaths due to swine flu. France has 27 confirmed deaths; Spain has 33 confirmed deaths; Norway has 29 confirmed deaths (Jan 4, 2010); Italy has 6 confirmed deaths; Belgium and Germany have 8 confirmed deaths; Sweden has 3 confirmed deaths (Nov 3); Malta and Greece has 3 confirmed deaths; Denmark, Finland ,^[308] Hungary and Luxemburg all have one confirmed death; Ireland and the Netherlands have 10 confirmed deaths each and the United Kingdom has 79 confirmed deaths along with the British government suggesting 55,000 new case of Swine Flu reported in the week up to the 16th of July 2009. The British government has also warned that deaths from swine flu this winter could be between 19,000 and 65,000 in the UK alone.

Hungary reported the first death in the country on July 22.^[66] Ireland reported its first death on August 7.^[309]

As of August 19, all European countries with the exception of the micro states San Marino and Vatican City have reported confirmed cases.

North America

Outbreak distribution in North America:
     Deaths     Confirmed cases     Suspect cases     No cases

     No deaths     1+ deaths     5+ deaths     10+ deaths     50+ deaths     100+ deaths     500+ deaths     1000+ deaths     5000+ deaths

In Canada, roughly 10% of the populace has been infected with the virus,^[310] with 363 confirmed deaths (as of December 8, 2009); there were over 10,000 confirmed cases when Health Canada stopped counting in July 2009.^[311] Canada began its vaccination campaign in October^[312][313] and 25% of the populace has since been immunized against H1N1, with Canada leading the world in the percentage of the population vaccinated.^[310][314] The pandemic was a concern in the months leading to the XXI Olympic Winter Games, which took place in Vancouver on February 2010.^[315]

Dr. José Ángel Córdova Villalobos, Mexico's Secretariat of Health, stated that since March 2009, there have been over 1,995 suspected cases and 149 deaths, with 20 confirmed to be linked to a new swine influenza strain of Influenza A virus subtype H1N1.^[316][317] "'As many as 23,000 Mexicans were likely infected with the swine flu virus,' Neil Ferguson of Imperial College London and colleagues reported in the journal Science."^[318] Soldiers mobilized by the government have handed out six million surgical masks to citizens in and around Mexico City.^[319] On April 24, 2009, schools (from pre-school to university level) as well as libraries, museums, concerts and any public gathering place, were shut down by the government in Mexico City and the neighboring State of Mexico to prevent the disease from spreading further; the schools in Mexico City, the State of Mexico, and the state of San Luis Potosí will remain closed until at least May 5.^[320] Marcelo Ebrard, Mexico City's mayor, has also asked all night-life operators to shut down their places of business for ten days to prevent further infections.^[321] On April 25, President Felipe Calderón declared an emergency which granted him the power to suspend public events and order quarantines.^[322] On April 26, the World Bank announced US$ 25 million in immediate aid loans to Mexico, an additional US$ 180 million for long-term assistance to address the outbreak, and advice on how other nations have responded to similar crises.^[319] On April 27, the Secretariat of Public Education announced that all schools in Mexico will remain closed at least until May 6.^[323] On April 28, the Mexico City government closed all restaurants and cinemas. The National History and Anthroplogy Institute also closed all its archaeological sites and museums, including the most famous Mayan and Aztec ruins, until further notice.

A semi-logarithmic chart of laboratory-confirmed A(H1N1) influenza cases by date according to WHO reports.^[211] Mexico, USA, and Canada are shown as a breakdown of the total.

In the United States, initial reports of atypical flu in two individuals in southern California led to the discovery of the novel swine flu virus by the CDC in mid-April. More than a hundred cases were confirmed in the next two weeks, spread through a dozen states.^[324] Outside of California and Texas, initial cases were all tied to recent travel to Mexico or close contact with those who had recently visited Mexico. St. Francis Preparatory School, a private school in New York, was the center of a large cluster of cases after a Spring Break trip by several students, and perforce one of the first U.S. schools to be closed as a public health measure during the early outbreak.^[325] Most of the cases in California and Texas are not linked and may reflect localized outbreaks of this virus in those areas.^[326] The disease was not as virulent outside of Mexico as within Mexico, for reasons not fully understood. The US declared a state of Public Health Emergency but this was said to be standard procedure in cases as divergent as the recent inauguration and flooding.^[327] On April 29, the US suffered its first confirmed death of swine flu,^[328] and on May 5 the first US citizen died from swine flu.^[329] As of June 6, there were 17 confirmed deaths from swine flu in the US.^[330] As of mid-May 2009 many states had abandoned testing for likely influenza cases unless serious illness and/or hospitalization were present.^[331] Because reported numbers represent only confirmed cases, they are a "very great understatement" of the total number of cases of infection, according to the CDC.^[332] The real number of swine flu cases in the United States could be 「upwards of 100,000,」 a top public health official estimated on Friday — far higher than the official count of 7,415 cases confirmed by laboratories.^[333] As of October 20, 2009, swine flu cases have reached over 256,000, with 2,800 deaths in the United States.

Caribbean

H1N1 in Caribbean and Central America     Deaths     Confirmed cases     Suspect cases     No cases

In Aruba, all passengers arriving by airplane or cruise ship were required to fill out a health questionnaire beginning on April 27, 2009.^[334] Hotels and resorts are required to report to authorities if any tourists are showing flu-like symptoms.^[334] The government of Aruba also ordered antiviral medication and other supplies from the Netherlands and the United States.^[334] No swine flu cases have been reported.^[334]

In Barbados, the first confirmed case of the H1N1 virus occurred on June 3, 2009.^[335] The second case was confirmed on June 6.^[336] The third case was confirmed on June 10.^[337] The fourth case was confirmed on June 17.^[338] Twenty five outstanding samples have been sent to the Caribbean Epidemiology Center, the results of which would confirm if there is in-country transmission.^[338]

Cuba suspended flights to and from Mexico for 48 hours.^[339] The first case of swine flu in Cuba was confirmed in mid-May.^[340]

The first two cases in the Dominican Republic were confirmed on May 27.^[341] On June 5, a 17 year old pregnant girl infected with the AH1N1 virus died. 93 cases were confirmed to this date.^[342]

As of 7 July 2009, there has been 33 confirmed cases of swine flu in Jamaica. Health Minister Ruddy Spencer told Parliament that the country has been placed on high alert. There has been heightened surveillance at health care facilities and port entry's.^[343]

In Trinidad and Tobago, one female has been confirmed as having contracted the H1N1 influenza.^[344]

In the Bahamas, ten students and teachers who arrived from Mexico in the last week of April are in quarantine.^[345]

Central America

     No deaths     1+ deaths     5+ deaths     10+ deaths     50+ deaths     100+ deaths     500+ deaths     1000+ deaths     5000+ deaths

The first two cases of the 2009 flu pandemic in Costa Rica, both of whom had traveled to Mexico, were confirmed on April 28.^[346][347] On July 31 local authorities announced that the country was selected among the sample countries that will be part of the test of the vaccine developed by Swiss pharmaceutical Novartis. The local sample will include 784 Costa Ricans ages 3 to 64. Besides Costa Rica, this vaccine prototype will be tested also in Mexico and the United States.^[348]

On August 11, it was confirmed that Costa Rica's President, Óscar Arias Sánchez, was infected with the A(H1N1) virus, becoming the first head of state sick with the A(H1N1) virus.^[349][350] President Arias return to his normal activities after one week of isolation at his home.^[351] As of October 15 the Costa Rican Ministry of Health had 1,530 confirmed cases, 1,242 pending cases, 7,404 already discarded, and 38 deaths.^[352]

Guatemala is checking all travelers arriving from Mexico for signs of flu and stopping anyone with symptoms of the virus at border crossings.^[353] On May 5, in a meeting with Health Minister and the Vicepresident, it was announced that an 11-year-old girl was infected with the AH1N1 virus.^[354] As of July 7 the Guatemala had 286 confirmed cases leading to two fatalities.^[355]

Honduras reported its first confirmed case of A(H1N1) flu on 27 May 2009. By June 7 the country had reported 67 cases, most of the cases on the city of San Pedro Sula and the Atlantic Coastline. There are few cases on other cities and areas. All airports and commercial sites as well as public events are monitored. As of July 7 there were 123 confirmed cases and one fatality.^[355]

As on June 4, 179 confirmed cases had been reported by Panamanian health authorities.^[356] Of these, 91 were male and 88 were female. Schools with positive cases are being disinfected. Thermal cameras had been deployed in Tocumen International Airport to identify sickness among arriving passengers.

As of July 7, El Salvador reported 319 confirmed cases, and Nicaragua 321. Panama and Nicaragua have not reported any fatalities.^[355]

Oceania

Researchers in Australia and New Zealand have reaffirmed that infants under the age of 1 year have the highest risk of developing severe illness from swine flu.^[357] Canadian health officials have reported that swine flu is hospitalizing three to four times as many children as regular seasonal flu.^[358]

     Deaths     Confirmed cases     Suspect cases     No cases

     No deaths     1+ deaths     5+ deaths     10+ deaths     50+ deaths     100+ deaths     500+ deaths     1000+ deaths     5000+ deaths

The first confirmed case in Australia was reported on May 9.^[359] As of July 3, 2009, Australia has 7,290 confirmed cases. The first Australian death was on June 19 and the total death toll has risen to 20.^[360] The alert level has been lifted from "delay" to "contain", giving authorities in all states the option to close schools if students are at risk.^[361] Australia has a stockpile of 8.7 million doses of Tamiflu and Relenza.^[362] At the beginning of the outbreak airlines were required to report passengers from the Americas with influenza symptoms, and nurses were deployed at international airports.^[362]

On May 30, New Zealand had 9 laboratory confirmed cases and 10 probable cases. All patients recovered. Over the month of June cases in New Zealand rose rapidly. On June 14 the Ministry of Health announced a 65% increase in cases in just 24 hours. On July 4, the Ministry of Health announced the first New Zealand deaths. There have been three confirmed deaths of patients who had tested positive for the flu, however two of them had known underlying medical conditions. The total number of confirmed cases has now reached 945.^[363]

Islands and Antarctica

No cases have been reported in Antarctica. Two cases were confirmed in the Pacific Islands. Both cases were confirmed on June 15, one in the Solomon Islands and another in Samoa.^[364][365] 5 cases has been confirmed in Fiji as of June 24 and 1 case in Vanuatu.

South America

Outbreak evolution in South America:     Deaths     Confirmed cases     Suspected cases     No reported cases

     No deaths     1+ deaths     5+ deaths     10+ deaths     50+ deaths     100+ deaths     500+ deaths     1000+ deaths     5000+ deaths

In Argentina, as of April 2009, passengers with influenza symptoms arriving from Mexico and United States were required fill out a form to be located should they experience any symptoms.^[366] In addition, the government has also stepped up safety checks, and thermal scanners are being used on airports to detect passengers with fever and other influenza symptoms. Flights from Mexico were also temporarily suspended as a precautionary measure.^[367] These measures however have proven to be largely ineffective. As of June 22, Argentina had 1,213 confirmed cases of swine flu and 10 confirmed deaths,^[368] increasing to 52 confirmed deaths ^[369] and an estimated number of as many as 100,000 affected people on July 2, as confirmed by the then newly appointed Minister of Health Juan Luis Manzur.^[370] As of July 14, the number of officially recognised cases skyrocketed, with 137 deaths,^[371] making the death toll in Argentina the second highest in the world, only behind the United States and surpassing that of Mexico.

As of April 2009, Brazilian airports would monitor travelers arriving from affected areas, under the direction of the National Sanitary Surveillance Agency (ANVISA). Air crews were trained on signs and symptoms of swine influenza so that passengers displaying symptoms would receive guidance from ANVISA upon arrival.^[372] As of June 4, there were 28 confirmed cases of swine flu in Brazil.

The first case of A(H1N1) flu in Chile was confirmed on May 17.^[373] On May 29, the Chilean Health ministry confirmed the number of cases of A-H1N1 had risen to 224.,^[373] the same day two more cases were confirmed.^[374] On June 3 Chile suffered its first confirmed death of swine flu, a 37-year-old man from Puerto Montt.^[375] To the date, and since the laboratory tests are no longer mandatory, the estimation of cases in Chile go up to 500.000 cases.^[373]

On May 3, 2009, Minister Palacio confirmed the first case of A(H1N1) in Colombia,^[376] in a 42-year-old person from Zipaquirá, who recently travelled to Mexico.^[377] According to Palacio, only one out of 18 tests sent to Atlanta was positive. The patient was isolated and put under medical treatment. On the same day, Palacio stated there were 108 suspect cases in the country.^[377] On April 27, the Government declared a "national disaster" state^[378] in order to face the emergency, which allowed health authorities to have a special budget to do so.^[379] The government purchased 400,000 oseltamivir (Tamiflu) doses, which will be distributed through the Social Protection ministry to the affected if there are confirmed cases.^[380]

Health officials are carrying out checks on people with flu symptoms entering the country from sea or air.^[381] On April 29, Ecuador closed its borders to Mexican citizens and foreigners of other nationalities arriving from Mexico for a period of 30 days.^[382] On May 15, Health officials confirmed the first case of AH1N1 flu in Ecuador .^[383] On May 20, the Health Department confirmed 7 more new cases of AH1N1, raising the total number of infected people to 8,^[384] the number has now risen to 41.^[385]

The first case of swine flu in Peru was confirmed on n May 14. On May 17, the second case was confirmed, an American-born man residing in Arequipa. He had returned from the US on May 12, not showing any symptoms until two days later.^[386] On May 18 a new case was confirmed, a scholar returning from a trip to Dominican Republic, that studied in the Altair school. another case of a scholar from the same trip to Dominican Republic. Student had contact with 3rd victim and both studied in the same school.^[387] The Governor of Callao ordered that all passengers from any infected country be checked before their arrival on Peruvian territory. Also, the Peruvian government must be warned of any case or symptom of fever. This step is in order to prevent any infections, since the main port and airport of Peru are located in Callao. Also, the government has prepared a special area at the Hospital "Daniel Alcides Carrión" to treat cases of this disease.^[388] Efforts are being made to examine slaughterhouses and they are screening incoming passengers from problem areas.^[389] All commercial flights from Mexico to Peru were suspended on April 29.

In Venezuela, controls have been raised at airports to prevent contagion from spreading. Travellers from the United States and Mexico with flu symptoms are being isolated until they are given the all clear. Pig farms in the country are being "closely inspected" and stockpiles of medicines built up.^[381] On May 28 the Health Minister, Jesús Mantilla, confirmed the first case of the A/H1N1 flu in a Venezuelan citizen who arrived in a flight from Panama. He was isolated to the place he is receiving treatment and his condition is stable.^[390] The following day, a second case was confirmed from another person who also arrived from the same flight.^[391]

Reporting bias

Epidemiologists caution that the number of cases reported in the early days of an outbreak can be very inaccurate and deceptive.^[392] This can be due to several causes, including selection bias, media bias, and incorrect reporting by governments.

One selection bias in epidemiology pertains to authorities in different jurisdictions looking at different sets of patient populations. For example, in the early days of the pandemic, doctors in Mexico may have been concentrating on patients in hospitals, rather than the larger vulnerable population, which may in part explain the higher mortality recorded in the country.^[392] Conversely, it is implausible that few, if any, have died in Mexico in recent months when Brazil and the United States have accumulated hundreds of additional lab-confirmed deaths in the same period. Media bias in reporting swine flu cases and deaths may skew incidence maps based on these media reports. Countries with poor health care systems and poor laboratory facilities may take longer to identify suspected cases, analyse those cases, and report them.^[393] Passive data collection methodologies (waiting for the patient to arrive at a health care facility) are considered inferior to active data collection techniques (performing random stratified sampling) due to various forms of selection bias.^[394] and because laboratory facilities to perform swift genetic tests on patient samples are not widely available.^[392] As of July 2009^[update] there are no properly controlled epidemiological studies for the 2009 swine flu outbreak.

Notes

1. ↑ All population figures are estimates for July 2009 from the source: "CIA - The World Factbook". Central Intelligence Agency. Archived from the original on 2009-09-08. http://www.webcitation.org/5jeGJerx8. Retrieved 2009-06-21. 

References

See also

• 2009 flu deaths by region

External links

• Influenza: H1N1 at the Open Directory Project
• Swine influenza, at the World Health Organization
• WHO's current Pandemic Influenza Phase

• Centres for Disease Control and Prevention (CDC): Swine Influenza (Flu)
• Medical Encyclopedia Medline Plus: Swine Flu
• Medical Encyclopedia WebMD: Swine Flu Centre
• H1N1 Statistics and Confirmed Worldwide Cases

2009 flu pandemic locations  Oceania   Africa   Asia   Europe   North America   South America