Anticipating The Flu Season Down Under

 

The red band signifies the tropics, which has no distinct flu season.  Viruses circulate there, at a low level, year round. – Credit Wikipedia

 

# 6859

 

 

Although flu season south of the equator won’t begin for several more months, health authorities in Australia and New Zealand are watching our busy flu season closely, and are warning the public to get vaccinated in advance of what could be a difficult flu season.

 

Watching what happens during the flu season in the opposite hemisphere can sometimes provide clues as to what the next flu season will bring.

 

Of course, it doesn’t always prove predictive. 

 

Last year, Australia and New Zealand saw a moderately active flu season, despite North America’s unusually quiet 2011-12 flu season (see The 2012 Flu Season Down Under).

 

While the media coverage is a bit hyperbolic (the flu season here is being described as moderately-severe), I’ve linked to a few recent news stories from down under to provide the `flavor’ of the coverage.

 

 

Warning over killer flu

Karen O'Sullivan, Yahoo!7 January 15, 2013, 3:46 pm

Health experts are warning a deadly flu that has spread across the United States will inevitably hit our shores.

Doctors want Australians to be prepared and to make sure they are vaccinated.

 

 

The devastating flu outbreak in the US could be on its way here

• Tory Shepherd From: news.com.au
• January 15, 2013 12:00AM

• 20 children have died from flu in the US
• Influenza strains travel the globe
• Australia should consider US season a "forewarning"

 

 

NZ preparing for deadly flu

Tuesday, 15 January 2013 10:50

Medical experts in New Zealand are bracing themselves for the arrival of a deadly flu that is sweeping the US which has already killed 20 children.

 

The southern hemisphere flu season doesn’t usually begin in earnest until May or June, but the flu vaccine will be available starting in March. Public health officials are urging early vaccination in order blunt the flu’s impact.

 

Since it takes roughly six months to produce enough flu vaccine for the next flu season, twice each year (February & September) experts gather to decide on the strains to include in the next vaccine.

 

Last September participants from divisions of the World Health Organization’s GISRS (Global Influenza Surveillance and Response System), along with members of OFFLU (the OIE/FAO Network on Animal Influenza), and other experts met in Beijing, China.

 

After group consultation, the experts opted for the same vaccine formulation that is currently being used in the northern hemisphere (see WHO: Southern Hemisphere 2013 Flu Vaccine Composition).

 

They recommended that trivalent vaccines for use in the 2013 influenza season (southern hemisphere winter) contain the following:

• an A/California/7/2009 (H1N1)pdm09-like virus;
• an A/Victoria/361/2011 (H3N2)-like virus;
• a B/Wisconsin/1/2010-like virus
  

They also recommended that quadrivalent vaccines containing two influenza B viruses contain the above three viruses and a B/Brisbane/60/2008-like virus.

 

 
Recent studies (see (A Comprehensive Flu Vaccine Effectiveness Meta-Analysis) have shown the flu shot to be moderately effective in preventing influenza – at least among healthy adults under the age of 65.

 

Similarly, last Friday in FluView Week 1 & MMWR Vaccine Effectiveness Report, we saw the first estimate of this year’s flu vaccine’s effectiveness, and early numbers suggest it to be around 62%.

 

For the elderly and for those with immune problems the flu vaccine’s effectiveness is often lower (see Study: Flu Vaccines And The Elderly).

 

In 2011, NFID - the National Foundation for Infectious Diseases - convened a group of experts to address the issues of influenza and the elderly. From that panel a 5-page brief has emerged, called: Understanding the Challenges and Opportunities in Protecting Older Adults from Influenza.

 

While the elderly generally see less protection from the flu vaccine, they state that older individuals may still mount a robust immune response. Even if the vaccine doesn’t always prevent infection in the elderly, studies suggest that the vaccine may blunt the seriousness of the illness in those over 65.

 

Although there is a pressing need for better flu vaccines (see CIDRAP: The Need For `Game Changing’ Flu Vaccines), flu shots are still considered the best preventative action you can take against influenza, and serious side effects are extremely rare.

 

So while not a guarantee against getting influenza, they do provide a moderate degree of protection.

 

Beyond the vaccine, the CDC also reminds us:

 

Take everyday preventive actions to stop the spread of germs.

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based hand rub.*
• Avoid touching your eyes, nose and mouth. Germs spread this way.
• Try to avoid close contact with sick people.
• If you are sick with flu–like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.)
• While sick, limit contact with others as much as possible to keep from infecting them.

»» Read More

Diary From The HMNZ Tahiti During The 1918 Pandemic

Troop Ship Tahiti in Wellington Harbor, circa 1918-19  Unknown Photographer

 

# 6617

 

For years historians, epidemiologists, and virologists have been attempting to peel back the cobwebs of time in order to analyze the deadliest pandemic in human history; the 1918 Spanish Flu Pandemic.

 

John Barry’s The Great Influenza: The Epic Story of the Greatest Plague in History, has probably done more to reawaken memories of that awful time than any other source, but many gaps in our knowledge remain.

 

Jeffrey  K. Taubenberger and David Morens - both researchers at NIAID – have added considerably to our understanding of the H1N1 virus and the events surrounding its emergence. Taubenberger was the first to sequence the the genome of the 1918 Spanish Flu virus while David Morens is a prominent medical historian.

 

See Morens & Taubenberger on Influenza’s History for a fascinating look back at influenza through the ages. Highly recommended.

 

Spanish Flu broke out in the spring and summer of 1918, while WWI was still underway. It so devastated troops on both sides of the conflict that historians believed it helped to hasten the end of the war.

 

Soldiers and sailors – living in cramped and often unhygienic quarters – bore the early brunt of the pandemic, while troop trains and ships helped to spread it around the globe.

 

While there are many horrific accounts from the pandemic – including some small villages in Alaska entirely wiped out – some of the best documented events occurred onboard troop ships. 

 

One of the most famous was the HMNZ Troop Carrier Tahiti, which during August-September of 1918 carried 1217 troops and crew (almost double what the ship was rated to carry) from New Zealand to Plymouth, England with provisioning stops at Cape Town and Sierra Leone. 

 

Since fever was reported in Sierra Leone, no crew or passengers reportedly went ashore , but locals came aboard to coal the ship.  Within a few days of leaving port, half the men on the ship were sick, and in a matter of days, more than 80 would perish.

 

The University of Otago has an well done 1-page synopsis of the investigation, which you can access here.

 

 

The detailed report, on which this exhibit is based, appeared in the CDC’s EID Journal in December of 2010.

Historical Review

Mortality Risk Factors for Pandemic Influenza on New Zealand Troop Ship, 1918

Jennifer A. Summers , Nick Wilson, Michael G. Baker, and G. Dennis Shanks

 

 

Adding another dimension to this story, Jennifer A. Summers returns to the October, 2012 edition of the EID Journal with excerpts from a recently uncovered diary, kept by one of the troops aboard that ship.

 

 

Pandemic Influenza Outbreak on Troop Ship—Diary of a Soldier in 1918

Jennifer A. Summers

Abstract

A newly identified diary from a soldier in 1918 describes aspects of a troop ship outbreak of pandemic influenza. This diary is the only known document that describes this outbreak and provides information not officially documented concerning possible risk factors such as overcrowding and the suboptimal outbreak response by military leaders. It also presents an independent personal perspective of this overwhelming experience.

(Continue . . . )

 

The diary entries make fascinating reading, as does the commentary provided by the author. Well worth following the link and to read in its entirety.

 

For more on the history and impact of the 1918 Spanish flu, you may wish to pay a visit to Flu.gov’s Pandemic history page, with offerings such as:

 

• We Heard the Bells
  Watch this film and explore the personal experiences of a diverse group of Americans during the 1918 flu pandemic.
• The Great Pandemic: The United States in 1918–1919
  Learn how the 1918 pandemic affected life in 1918 and the nation’s health care system. See historical artifacts from the pandemic, including ads, newspapers, and photographs. Read stories and anecdotes of the impact of the Great Pandemic in individual states.
• Pandemic Influenza Storybook
  Read personal recollections of the 1918 and 1957 flu pandemics.
• The Deadly Virus: The Influenza Epidemic of 1918View the National Archives and Records Administration’s documents and photos from the 1918 flu pandemic.
• Toxic Traces: What Made the 1918 Influenza Virus So Deadly?
  Read how National Institute of Allergy and Infectious Disease-supported researchers are looking to the 1918 flu pandemic for ways to fight future pandemics.
• Pandemic Influenza––Past, Present, Future: Communicating Today Based on the Lessons from the 1918–1919 Influenza Pandemic (PDF – 1.72 MB)
  Learn how the 1918 pandemic affected daily life in the United States and which lessons can be used to prepare for pandemics today.
• The American Experience: Influenza 1918 (Public Broadcasting Service)
  Watch PBS’s documentary on "the worst epidemic in American history."
• Influenza of 1918 (Spanish Flu) and the US Navy
  Read about the Navy medical professionals who fought the 1918 flu pandemic in stories collected by the Navy Department Library.

»» Read More

The 2012 Flu Season Down Under

The red band signifies the tropics, which has no distinct flu season.  Viruses circulate there, at a low level, year round. – Credit Wikipedia

# 6441

While most of the Northern Hemisphere is basking in summer warmth and seeing very little flu activity (Hong Kong being an exception), it is winter south of the equator and flu season is well underway in Australia, New Zealand, and parts of South America and Africa.

 

Watching what happens during the flu season in the opposite hemisphere can sometimes give us clues as to what we might expect in the fall.

 

Of course, it doesn’t always prove predictive. 

 

After the mildest flu season in memory in the Northern Hemisphere, it appears that Australia and New Zealand are getting hit harder, and earlier than usual.

 

First stop, a media report from the West Australian, then we’ll take a look at the latest surveillance data.

 

 

Pressure mounts with different flu virus

Peta Rasdien, The West Australian July 19, 2012, 7:39 am

The earliest start to the flu season in 10 years and the rise of a strain known to cause more severe illness is putting pressure on WA's already stretched health resources.

(Continue . . . )

 

The `different’ flu virus is the seasonal H3N2 virus – which has antigenically drifted slightly away from the vaccine strain currently in use (see WHO: Southern Hemisphere 2012 Flu Vaccine Composition).

 

The existing vaccine contains the A/Perth/16/2009 (H3N2)-like virus, which is hoped to be at least somewhat effective against the evolving virus.

 

This fall, a new vaccine will be introduced that contains the updated A/Victoria/361/2011 (H3N2)-like virus (see WHO: Northern Hemisphere 2012-2013 Flu Vaccine Composition).

 

 

Historically, years where the H3N2 virus has been the dominant strain tend to produce worse flu seasons.  The virus often hits harder than H1N1, and is more likely to target the elderly.

 

From New Zealand’s ESR Public Health Surveillance, we get these latest numbers in their Influenza Weekly Report 2012/28.

 

As you can see, the weekly consultations for ILI’s (Influenza-like Illness) are climbing like a homesick angel, and are running well ahead of the reports from the past 2 years. 

 

While ILI activity in NZ is heavy, it does not reach the epidemic threshold (400 per 100K).

 

The week 28 report summary reads:

 

ILI through sentinel surveillance was reported from 19 out of 20 District Health Boards (DHB) with a national consultation rate of 102.8 per 100 000 (399 ILI consultations). A total of 905 swabs were received from sentinel (79) and non-sentinel (826) surveillance.

 

331 viruses were identified: A(H3N2) (232), A (Not subtyped) (35), A(H1N1)pdm09 (31), B (Lineage not determined) (26), A/Perth/16/2009 (H3N2)-like (5) and B/Wisconsin/1/2010-
like (2)

 

 

About 70% of the viruses identified were H3N2, while only 10% were the 2009 H1N1 strain.

 

The situation in Australia appears similar, although the latest surveillance numbers are not quite as current as what we have from New Zealand.

 

This from Australia’s Department of Health and Ageing.

 

Australian influenza report 2012 - Current report: No 2 - 9 June to 22 June 2012

Summary

• Across all surveillance systems, influenza activity has continued to increase this fortnight.
• All jurisdictions have reported increases in influenza detections above background levels, with South Australia, Victoria, New South Wales, the Australian Capital Territory and the centre of the Northern Territory reporting significant recent increases in activity.
• Influenza-like illness (ILI) activity has continued to increase, with the seasonal increase occurring slightly earlier than in previous years (excluding 2009).
• During this fortnight there were 2,233 laboratory confirmed notifications of influenza, almost double the number of notifications from the previous fortnight. New South Wales, Queensland and South Australia continue to report the highest number of notifications.
• Nationally, influenza A(H3N2) is the predominant circulating strain with some co-circulation of influenza B. Influenza A(H3N2) is predominant across most states and territories, however influenza B represents around 75% and 40% of all notifications in the Northern Territory and Western Australia, respectively. So far in 2012 there have been very few notifications of pandemic (H1N1) 2009.
• As at 22 June 2012, there have been 6,027 confirmed cases of influenza reported. Excluding 2009, notifications of influenza in 2012 have started their seasonal increase slightly earlier in comparison with previous years.
• Influenza associated hospitalisations have continued to increase this fortnight, particularly at the South Australian and Northern Territory sites. Overall, 40% of hospitalisations have been associated with influenza B infections, mostly reported from the Northern Territory. Amongst other jurisdictional sites, influenza A is more common.
• The WHO has reported that the influenza season has not yet started in the temperate countries of the southern hemisphere, although several countries, including Australia, Chile, Paraguay and South Africa have reported small but sustained increases of influenza virus detections. Influenza A(H3N2) viruses have been the most commonly detected in recent weeks in the southern hemisphere temperate region.
• 

Based on this chart, this year’s ILI activity is off to the fastest start in Australia since the H1N1 pandemic of 2009.

As far as what the southern hemisphere’s flu season tells us about the fall flu season ahead?

 

Well, the old adage is that if you’ve seen one flu season, you’ve seen one flu season.

 

Influenza viruses are notoriously unpredictable, and flu seasons that span the globe, even more so.  We won’t know what kind of flu season we are going to have until we’ve had it.

 

We will continue to watch the flu season evolve to our south, however, looking for any clues that might arise.

 

But whatever comes, we do have one advantage over our friends south of the border this year; the new flu shot with antigens expected to be more protective against the drifted H3N2 virus that will be available this fall.

 

Making getting the seasonal flu shot this fall all the more important this year.

 

Add in the routine practicing of good `flu hygiene’ (covering coughs, washing hands, staying home when sick), and you can substantially decrease you odds of getting the flu this coming winter.

»» Read More

Lancet: Increasing Incidence Of Infectious Diseases In New Zealand

 

 

# 6158

 

 

Forty-three years ago (1969), Surgeon General of the United States William H. Stewart, famously (and as it turned out, prematurely) declared,  "The war against diseases has been won."

 

And for a time, it seemed he might be right.

  

With the advent of the Salk Vaccine in 1955, we finally had the tool with which to eradicate the last great childhood scourge in this country; Polio. By 1963, an early measles vaccine had been developed, and in the late 1970s significant improvements had been made in the existing mumps vaccine.

 

And the tremendous victory over smallpox – now vanquished from the planet for more than 3 decades – seemed only to prove the point.

 

A telling graphic from the MMWR of Dec 1999, Achievements in Public Health, 1900-1999: Control of Infectious Diseases shows the progress made during the 20th century in the battle against infectious diseases.

 

 

 

But this victory was short-lived. By 1996 you can begin to see the uptick in infectious disease deaths, after reaching its nadir in 1980.

 

Since Stewart’s pronouncement we’ve seen a Swine Flu  pandemic, a SARS epidemic, the return of the H1N1 virus in 1977 plus the emergence of previously unknown pathogens like HIV, Lyme Disease, Nipah, Hanta and Hendra (among others).

 

We’ve watched the global spread of MRSA, along with the recent arrival of of NDM-1 and other Carbapenemases that threaten the viability of our antibiotic arsenal.  Even Gonorrhea, once easily cured, threatens with new drug resistant strains.

 

And we’ve seen an explosion in dengue and chikungunya cases, the global persistence of malaria, along with outbreaks of Ebola, CCHF, and other exotic diseases.

 

Even old scourges, once thought on the way out, are showing new signs of life . . . like Pertussis, measles, and polio. Perhaps most troubling of all has been the emergence of increasingly drug resistant strains of tuberculosis.

 

On average –  researchers have discovered one new zoonotic threat a year over the past three decades.

 

 

Admittedly a lot of these emerging infectious diseases are predominantly found in developing, or under-developed countries.

 

Non-communicable diseases – like cancer, coronary artery disease, diabetes, and tobacco-related illnesses – are generally thought of as being the primary health threats in developed countries.

 

And in terms of total numbers, that holds true.

But infectious diseases are on the rise in the developed world, as is once again confirmed by the following report on a nationwide epidemiological survey of New Zealand from The Lancet.

 

 

The Lancet, Early Online Publication, 20 February 2012

doi:10.1016/S0140-6736(11)61780-7

Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study

Dr Michael G Baker MBChB a, Lucy Telfar Barnard PhD a, Amanda Kvalsvig MBChB a, Ayesha Verrall MBChB a, Jane Zhang MSc a, Michael Keall PhD a, Nick Wilson MBChB a, Teresa Wall DPH b, Prof Philippa Howden-Chapman PhD a

Findings

Infectious diseases made the largest contribution to hospital admissions of any cause. Their contribution increased from 20·5% of acute admissions in 1989—93, to 26·6% in 2004—08. We noted clear ethnic and social inequalities in infectious disease risk. In 2004—08, the age-standardised rate ratio was 2·15 (95% CI 2·14—2·16) for Māori (indigenous New Zealanders) and 2·35 (2·34—2·37) for Pacific peoples compared with the European and other group. The ratio was 2·81 (2·80—2·83) for the most socioeconomically deprived quintile compared with the least deprived quintile. These inequalities have increased substantially in the past 20 years, particularly for Māori and Pacific peoples in the most deprived quintile.

Interpretation

These findings support the need for stronger prevention efforts for infectious diseases, and reinforce the need to reduce ethnic and social inequalities and to address disparities in broad social determinants such as income levels, housing conditions, and access to health services. Our method could be adapted for infectious disease surveillance in other countries.

 

Retrospective epidemiological analyses such as this one are always subject to a certain degree of error.

 

As this study is based on hospital admissions, it is likely that milder infections are under-represented. Coding errors, or the re-evaluation of original diagnosis codes based on the judgment of the reviewers, may further complicate matters.

 

The authors cite economic and social disparities as prime factors in the increase in infectious diseases.

 

Problems that are hardly unique to New Zealand. 

 

While almost 75% of their hospitalizations still come as the result of non-communicable diseases, the trend over the past two decades shows that infectious diseases are gaining ground.

 

Up by roughly 30% since 1989.

 

In the discussion section, the authors write:

 

The large increase in admissions for infectious diseases has important health and economic implications, and challenges prevailing views about the waning importance of infectious diseases. New Zealand seems to have the dual burden of rising non-infectious diseases, without having controlled the incidence of infectious disease.

 

The increase is equivalent to an additional 17 000 hospital admissions per year compared with the expected incidence, had the proportion of admissions caused by infectious diseases in 1989—93 continued to the present.

 

 

For more on this apparent pendulum swing back towards emerging infectious diseases, you may wish to revisit a blog I wrote more than a year ago called:

 

The Third Epidemiological Transition

»» Read More

New Zealand : Airline Passengers Quarantined

 

 

 

# 6136

 

On an otherwise quiet Sunday afternoon here in the states, news wires are carrying reports of a Boeing 777-200 inbound from Japan that has landed at Auckland’s airport with roughly 60 passengers exhibiting flu-like symptoms.

 

While this sounds like the opening scene to a pandemic disaster movie, in all likelihood this will sorted out to be standard H3N2 influenza which is currently spreading across much of Japan. 

 

The sudden onset of so many cases during this flight has obviously set off alarm bells for local health authorities, however.

 

New Zealand has developed one of the most aggressive airport disease surveillance and interdiction systems in the world. 

 

For now, local media is reporting that all 274 passengers remain on the plane, and health authorities are setting up some sort of quarantine.

 

A couple of reports:

 

First from TVNZ

 

Health scare at Auckland Airport

breaking news

Published: 9:48AM Monday February 13, 2012

A major health response is under way after an Air New Zealand plane landed at Auckland Airport with children with flu-like symptoms on-board.

 

A group of 60 passengers arrived into Auckland off NZ90 from Narita, Tokyo, this morning with the symptoms.

 

Air New Zealand is following public health procedures and has advised the Auckland Regional Public Health Service.

(Continue . . .)

And this report from 3News New Zealand.

 

Flu-like symptoms on Air NZ Tokyo flight

By 3 News online staff

Sixty passengers arriving at Auckland International Airport this morning have reported flu-like symptoms, Air New Zealand has confirmed.

 

Flight NZ90 from Tokyo landed a short time ago and passengers remaining on the plane could be seen on the plane wearing face masks.

(Continue . . . )

 

 

While the odds favor this outbreak turning out to be something fairly mundane, I’ll keep an eye on it and update this blog if I hear more.

»» Read More

A Feverish Debate

 

 

 

# 5687

 

Photo Credit –CDC PHIL

 

A topic I’ve written about several times in the past is back in the news again; the advisability of using antipyretic meds (ibuprofen, acetaminophen or paracetamol, etc) for flu-related fever.

 

The eye-catching headline and lede in yesterday’s New Zealand Herald reads:

 

'Don't use paracetamol for fever'

By Martin Johnston

5:30 AM Monday Jul 11, 2011

A respected scientific group has recommended not using paracetamol and several other drugs to reduce flu-related fever, saying they may increase the risk of death.

(Continue . . . )

 

 

The respected scientific group referenced in the article above is Wellington based Medical Research Institute of New Zealand. And their advice runs contrary to what we usually hear from our doctors, the CDC, and the World Health Organization.

 

Constant readers will recall that last May I wrote (see It Gives You Fever) about about a clinical trial this research group was about begin that would examine the merits and risks of taking antipyretics with influenza.

 

The concern is that when we take fever reducers, we lower the body’s temperature to provide symptomatic relief – but we also create a more favorable environment for the virus to replicate.

 

Essentially trading comfort for circumventing the body’s natural defense mechanism.

 

Last year, in A Hot Topic For Further Research I wrote about new research that suggested (but fell short of proving) that we may be better off carrying a bit of a fever – rather than reaching for the pill bottle -  when we have the flu.

 

And while that isn’t exactly a new idea, the evidence to support it has been limited.

 

The study – again conducted by the Medical Research Institute of New Zealand -  appeared in the Journal of the Royal Society of Medicine (registration required for access) – and provided a retrospective analysis of previous animal (not human) studies on the outcomes of the treatment of bacterial and viral infections with antipyretics.

 

The effect on mortality of antipyretics in the treatment of influenza infection: systematic review and meta-analysis

Sally Eyers, Mark Weatherall, Philippa Shirtcliffe, Kyle Perrin, and Richard Beasley

v.103(10); Oct 1, 2010

 

In a review of the existing literature, researchers at the Medical Research Institute of New Zealand and Capital & Coast District Health Board, identified 8 (non-human animal) studies that met their inclusion criteria.

 

They found that the risk of mortality increased by roughly 33% when antipyretics were used in influenza infected animals.  This risk was observed with aspirin, paracetamol, and diclofenac.

 

As I pointed out at the time, there were a lot of limitations to this study, not the least of which is that research on mice, chickens, and ferrets isn’t always applicable to humans.

 

Hence the need for the clinical trial on humans underway in New Zealand.

 

From the Medical Research Institute’s website, a description of goals of the clinical trial.

 

The effect on mortality of antipyretics in the treatment of influenza

Antipyretics are recommended for the symptomatic treatment of influenza infection.  However there is evidence that fever is a protective physiological response, that treating fever secondary to infections may be harmful and that human tropic influenza viruses are variable temperature-sensitive.

In a systematic review and meta-analysis we have identified that in animal models treatment with antipyretics for influenza infection increases the risk of mortality.  There are no randomised controlled placebo-controlled trials of antipyretic use in influenza infection in humans that reported data on mortality and a paucity of clinical data by which to assess their efficacy.

In response to these findings the MRINZ is now undertaking a placebo-controlled randomised trial of paracetamol use in influenza infection. This study is funded by the Health Research Council of New Zealand.

 

The results of that trial are not yet available, and so while the Medical Research Institute is publicly questioning the value of reducing fevers with influenza, they are not yet calling for health authorities to change their existing stance on the use of antipyretics.

 

They also state that using these meds as a pain reliever for muscle aches and headaches when you have influenza, is a reasonable practice.

 

And to round out this debate, the New Zealand Self Medication Industry Association (who have a vested interest in the sale of these products) has weighed in with the following press release.

 

Tuesday 12 July 2011, 12:13pm

Media release from New Zealand Self-Medication Industry Association

The New Zealand Self-Medication Industry Association (SMI), the industry body representing non-prescription consumer healthcare products, said today it was aware of a recommendation by the Wellington-based Medical Research Institute that antipyretics, such as paracetamol, ibuprofen and aspirin, not be used to reduce flu-related fever.

 

"We have only just received this information and, as the Institute itself said, there was insufficient evidence for the Ministry of Health to change its current position on these products. It's important people do not overreact and stop using antipyretics altogether.

 

Paracetamol and ibuprofen, for example, are well recognized for the relief of pain," commented SMI executive director Tim Roper.

"Fever management guidelines highlight that it is important to treat the patient and not the thermometer - SMI and its members endorse this approach. We are confident that if this approach is used, that these medicines can be used safely.

"Nevertheless, our members welcome the opportunity to work with Medsafe to discuss any matters that may arise, after the Ministry has reviewed the new information."

 

 

Although the jury is still out on all of this (and I’ve not discarded the Tylenol from my medicine cabinet), the American Academy of Pediatrics (AAP) released a report earlier this year on the use of antipyretics in children, suggesting that we ought not over-treat fevers.

 

Clinical Report—Fever and Antipyretic Use in Children

Janice E. Sullivan, MD, Henry C. Farrar, MD,

 

ABSTRACT EXCERPTS

 

Fever in a child is one of the most common clinical symptoms managed by pediatricians and other health care providers and a frequent cause of parental concern. Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a “normal” temperature.

 

Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection. There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications.

 

Thus, the primary goal of treating the febrile child should be to improve the child's overall comfort rather than focus on the normalization of body temperature.

 

(Continue . . . .)

 

 

And lastly, I would mention that in 2009 I wrote about some of the downsides to taking anti-inflammatory drugs like Aspirin, Tylenol, and Ibuprofen in a blog called  A Few Inflammatory Remarks.

 

It concerned a Lancet study that suggested giving babies acetaminophen (Tylenol) right before or immediately after getting a vaccination may inhibit or lower their immune response.

 

It also discussed several studies from the University of Rochester, that indicate the use of NSAIDs could lower the body’s antibody response.

 

It is axiomatic that there is no such thing as a 100% safe, 100% benign drug – even those you can buy over the counter.  

 

If there is a health benefit to be had, we must weigh that against the (usually very slight) risks of taking the these meds.

 

While the overall risks of taking these drugs are likely exceedingly small, hopefully we’ll soon have research that will help quantify the risks and rewards of using these common fever reducing medicines.

»» Read More

5.5 & 6.0 Aftershocks Strike Christchurch

 

 

# 5623

 

An Active Ring of Fire

Original Map – USGS

 

Overnight here in the USA, and early afternoon local time (1pm & 2:20pm), two strong and very shallow earthquakes struck near Christchurch, New Zealand, reportedly injuring a small number of people and causing major power outages and widespread local damage.

 

This comes a little less than four months after the devastating 6.3 mag aftershock (see NZ: Aftershocks, Rescue Attempts, Casualties, And The Mounting Toll) of the September 2010 quake, and at a time of year when winter nighttime temperatures are dropping uncomfortably to near freezing.

 

Kiwibird, an editor and senior moderator of FluTrackers, has started a new news thread on the new quake. You’ll find local news stories, photos, and first hand accounts posted there.

 

As the residents of Japan and Chile can testify, aftershocks – sometimes only a magnitude less than the original quake – are common during the months and years following a major earthquake.

 

They can pose a continual physical danger, and ongoing psychological challenge, to the to residents of the stricken area.

 

The USGS has  released this Tectonic Summary on these latest temblors.

 

The June 13, 2011 South Island, New Zealand earthquake is a continuing part of the earthquake sequence that initiated with the magnitude 7.0 September 3, 2010 Darfield, New Zealand earthquake. The June 13, magnitude 6.0 earthquake is a dominantly strike-slip faulting earthquake that is at the eastern end of the inferred rupture of the 21 February 2011 magnitude 6.1 earthquake. Both this magnitude 6.0 event and the previous magnitude 6.1 event have an inferred fault plane striking approximately east-northeast. The entire earthquake sequence is broadly associated with regional plate boundary deformation as the Pacific and Australia plates interact in the central South Island, New Zealand.

 

This latest earthquake, similar to the February 21 earthquake, is close to the main population centers of Christchurch, New Zealand. This region has suffered substantial casualties and damage to buildings, infrastructure, and lifelines from a series of events starting with the February 21 earthquake. Additionally, the earthquakes close to Christchurch caused substantial liquefaction in residential areas. The June 13 earthquake was preceded by a nearby magnitude 5.2 foreshock, about 1 hour and 20 minutes earlier. There is no specific surface fault that has been observed for the post-September 3 earthquakes near Christchurch, or directly linking them to the observed September surface fault rupture. There have however been a substantial number of aftershocks forming a continuous swath extending from the September 3 events to the June 13 earthquake.

 

As I wrote last March in The Ring Of Fire, we live on a seismically active planet, and while `Great Quakes’ are relatively rare (happening somewhere in the world – on average – of once a year), very damaging quakes of between 7.0-7.9 happen on practically a monthly basis.

 

(USGS chart)

 

And quakes the size of the one that struck Christchurch today happen about 10 times each month.  

Many,  of course, don’t occur this close to a populated area and this shallow, and so their impact isn’t always felt.

 

Tens of millions of people, however, live in high risk zones - and yet - many are unprepared for these all-too-common disasters. 

 

No matter where you live, the images coming out of Japan, New Zealand, Haiti and Chile over the past couple of years should serve as a wake-up call to become better prepared.

 

From the USGS Great Southern California Shakeout website,  we’ve this 4 and 1/2 minute video called Preparedness Now (Streaming | Video) that  “depicts the realistic outcome of a hypothetical, but plausible, magnitude 7.8 earthquake on the San Andreas fault in Southern California.”

 

 

Which makes this a pretty good time to remind my readers about the study last year (see Revised Risk Of `The Big One’ Along San Andreas Fault) that suggests that Southern California may be more overdue for another major quake than previously thought.

 

For more on earthquake and general disaster preparedness, you might wish to look at these essays as well.

 

The L. A. County Emergency Survival Guide

An Appropriate Level Of Preparedness

FEMA Asks: Are You Earthquake Prepared?

Inside My Bug Out Bag

 

And of course, Ready.gov  and FEMA are great resources for earthquake, and general, disaster preparedness information.

»» Read More

NZ: Aftershocks, Rescue Attempts, Casualties, And The Mounting Toll

 

 

# 5331

 

 

Damage reports continue to come in from quake stricken Christchurch overnight as rescuers sift through pancaked buildings looking for survivors. 

 

The news is grim, with reports of scores still trapped, and dozens of fatalities.  Cold temperatures and rain are not only making residents – many unable or unwilling to stay indoors – miserable, but are also complicating rescue and cleanup activities.

 

The NZ Herald has extensive coverage, including:

 

Christchurch Earthquake: Workers trapped in crushed buildings

10:03 PM Tuesday Feb 22, 2011

One of the buildings damaged by the 6.3 earthquake. Photo / Mark Mitchell

Up to 35 workers are trapped in two prominent Christchurch buildings, hard hit in today's 6.3 magnitude quake.

Thirty people are believed trapped in the Pyne Gould financial services building on Cambridge Terrace, with another five trapped in the Christchurch Press building.

(Continue . . . )

 

 

Despite their smaller size, the city has been damaged far more heavily by this latest quake, and the numerous ongoing aftershocks, that it was during the September 7.1 magnitude quake. 

 

These temblors are both closer in to the center of the city (10 km) and shallower (3 km).

 

With winter approaching, and a number of homes destroyed (and many of those still habitable likely to have sustained additional chimney damage), residents will find many new challenges ahead.

 

The physical damage of an earthquake can take years to recover from.   The emotional damage – for some – can last a lifetime.

 

Many Christchurch residents had spent the last few months working to put their houses, businesses, and lives back in order after the September quake, only to find their efforts undone in a matter of seconds by last night’s temblor.

 

And the numerous aftershocks (several dozen over 3.5 magnitude in the first 10 hours) are an abrupt and ongoing reminder that the earth remains violent and uncertain beneath their feet.

 

While not approaching the impact of last year’s Haitian earthquake, the misery, heartache, and economic toll of last night’s quake are quite substantial and serve as another reminder that disasters can strike anywhere, and at any time.

 

I’ll return in my next blog with a long list of earthquake and disaster preparedness information.

»» Read More

NZ: 6.3 Magnitude Earthquake Hits Christchurch

UPDATED 3rd Time  2120Hrs EST

 

 

USGS Latest Earthquakes in the World - Past 7 days

Main earthquake & two strong aftershocks (plus many smaller ones not listed)

# 5330

 

 

Details are sketchy at this hour, but another large earthquake has struck New Zealand at 12.51pm local time, reportedly centered 10 kilometers south of the city at a depth of five kilometers.

 

This is the largest temblor since the 7.1 quake last September.  Many structures in the region were badly damaged during the 2010 event, and serious additional damage is likely from this latest quake.

 

This first report via Radio New Zealand.

 

A huge 6.3 earthquake has hit Christchurch, causing widespread destruction in the city centre.

Mayor Bob Parker says it felt like a whole new earthquake, not just an aftershock of the 4 September 7.1 quake. "It was very, very strong," he says.

 

Mr Parker advises people not to drive, given the state of the roads.

 

Radio New Zealand's reporter says staff at the Christchurch newsroom had to cling to their desks during the shaking. Large filing cabinets toppled.

(Continue . . . )

 

 

UPDATE:   Audio feed of Radio New Zealand news feed available at:

http://www.radionz.co.nz/audio/live/rnzi/adaptive.asx

 

7News Live TV coverage

http://au.news.yahoo.com/video/national/watch/23188303/23188288/

 

Twitter   #NZEQ    #EQNZ  #CHRISTCHURCH

»» Read More

NZ: The H1N1 Beat Goes On

 

 

 

# 4820

 

Although no longer considered a pandemic by the World Health Organization, novel H1N1 hasn’t gone away. 

 

H1N1 is expected to be a major component in this fall’s flu season north of the equator, and is currently fueling flu outbreaks (along with H3N2 and Flu B) in the tropics and some southern hemisphere nations.

 

In New Zealand – which has seen a slow start to their flu season – consultation rates for ILIs (Influenza-like illnesses) have nearly tripled over the past several weeks.

 

While nowhere near the level of ILIs reported during the height of last year’s pandemic outbreak, the level of consultations are currently above that seen at anytime during the 2008 flu season.

 

Here are some excerpts from the New Zealand Ministry of Health’s latest (#201) Swine flu Update.

 

9 August 2010

Pandemic Influenza H1N1 2009 (swine flu) - Update 201

Influenza H1N1 activity is continuing to increase, and the Ministry of Health is now providing twice-weekly updates.

 

As at 8am this morning, there have been 454 hospitalisations of lab-confirmed pandemic influenza H1N1 this year to date in New Zealand, including 14 people currently in intensive care with confirmed H1N1. There have been a total of 67 admissions of confirmed H1N1 to intensive care so far this year.

 

These figures do not include influenza-like illness among people admitted to hospital without a positive H1N1 lab test result.

 

Pandemic influenza H1N1 is the most common strain of influenza circulating in the community, although most people will not be tested for it. For the majority of people it's a mild to moderate illness, but for some it can be serious.

 

So far this year there have been nine deaths reported as linked to swine flu. Six of these deaths have so far been confirmed as being due to swine flu. The three deaths reported since Monday's update - all confirmed as due to swine flu - occurred in the Waitemata, Auckland and Waikato DHB areas.

 

<SNIP>

GPs are continuing to see increasing numbers of people with influenza-like illness. In the last week there was a notable increase in the number of pre-schoolers being seen by GPs.

Weekly consultation rates for influenza-like illness in New Zealand, 2008-2010

Source: Institute of Environmental Science and Research, Influenza Weekly Update 2010/32

»» Read More

NZ And Australia Seeing Increase In Flu-Like Illnesses

 

 

# 4744

 

 

After a very slow start this summer, there are indications that the levels of flu-like illness in parts of New Zealand and Australia may be picking up.

 

Two quick reports this morning. 

 

One from Auckland, NZ and the other from Canberra, Australia.  In both countries, the overall level of influenza remains lower than last year, but they are reporting regional `pockets’ of  heavy `viral’ activity.

 

How much of this is due to pandemic H1N1 (as opposed to other flu/respiratory viruses), and whether this is a trend that will continue to spread, is something we will have to wait to see.

 

 

Hospitals busy with spike in winter illnesses

The Public Health Service says pregnant women are especially vulnerable and should see a doctor if they get unwell

Thu, 22 Jul 2010 6:16p.m.

By Michael Morrah

There has been a sudden increase in the number of people in Auckland contracting H1N1 – the virus commonly referred to as swine flu.

 

The Public Health Service says pregnant women are especially vulnerable and should see a doctor if they get unwell.

 

It comes as hospital departments around the country struggle with an influx of illness.

 

St John paramedics and staff at Auckland Hospital have been busy; there has been more trauma, more flu; more people turning up for help as winter starts to bite.

 

“We've just had out busiest-ever weekend, we saw more than 340 patients as a complex,” says Auckland Emergency Department Clinical director Dr Tim Parke.

(Continue .  .  . )

 

A similar story comes from Canberra Australia.

 

 

Emergency departments full

Posted Thu Jul 22, 2010 9:06am AEST

 

Canberra's emergency departments are busier than ever, with more people presenting than in July last year during the swine flu epidemic.

 

The Health Minister Katy Gallagher says on average the Canberra Hospital's emergency department is seeing more than 160 people a day, and numbers are up at Calvary Hospital as well.

 

The Government has attributed the spike to more people presenting with asthma, chest pains and viral conditions.

(Continue . . . )

»» Read More

NZ Influenza Surveillance: Week 25

 

 

# 4689

 

Since influenza activity usually dwindles during the summer months in the northern hemisphere (excluding the tropics), we look to countries south of the equator for influenza in June, July and August.

 

New Zealand, Australia, and South Africa are three southern hemisphere population centers with good surveillance and reporting, and from them we can sometimes can get a hint of what may lay ahead for our flu season in the fall.

 

The level of influenza in 2010 has, thus far, been low in these countries, but there are indications that it may be picking up.

 

First, a link to this week’s surveillance from New Zealand, and a couple of graphics from that report, then a link to this week’s press release from the Ministry of Health.

 

 

INFLUENZA WEEKLY UPDATE
2010/25:  21-27 June 2010

 

SUMMARY OF THIS REPORT:

•  Influenza-like  illness (ILI)  through sentinel surveillance was reported from 19 out of
20  District  Health  Boards  (DHB)  with  a  national  consultation  rate  of  29.0  per 100 000 (106 ILI consultations). 

•  One hundred and forty-two swabs were received from sentinel (26) and non-sentinel surveillance  (116).  Eight  viruses  were  identified,  three  from  sentinel:  pandemic (H1N1) 09 (2) and A (H3N2) (1), and five from non-sentinel surveillance: pandemic (H1N1) 09 (3) and A (not sub-typed) (2).  

•  Since  January  2010,  322  cases  of  pandemic  (H1N1)  09  have  been  recorded  in EpiSurv3
, six of which were reported in week 25.  

 

 

Once again, we are seeing faint traces of seasonal H3N2 showing up in surveillance reports. 

 

Whether that represents a `last gasp’ of this strain, or is an indication of its resilience in the face of a pandemic strain, is difficult to gauge at this point.  

 

 

 

While still below the baseline, influenza-like activity in New Zealand has shown an increase two weeks in a row.  

 

The map below shows that the health districts of Waikato and Capital and Coast are reporting levels above the baseline, while most of the rest of the country is seeing lesser activity.

 

 

 

1 July 2010

Pandemic Influenza H1N1 2009 (swine flu) – Update 192

Overall influenza activity is gradually increasing and is at the level usually seen at this time of year. The pandemic influenza virus is circulating in our communities, though the rate of consultation for influenza-like illness identified through sentinel general practices remains below the baseline level.

(Continue . . .)

»» Read More

New Zealand Seroprevalence Study On H1N1

 

 

# 4622

 

 

Last November it was announced that New Zealand would conduct a major seroprevalence study of their population to see how many people had pre-existing immunity to the novel H1N1 virus, how many were infected over the winter, and how many remained susceptible to the virus.

 

For details on that announcement see New Zealand To Conduct Seroprevalence Studies.

 

Today we’ve got the results of this study, as summarized in this Ministry of Health (MOH) release (hat tip Sally Furniss on FluTrackers).   

 

As you read it, remember the total population of New Zealand is about 4.2 million people. I’ll return with a little more information after the report.

 

 

Media Release

4 June 2010

Pandemic Influenza H1N1 2009 (swine flu) – Update 188

Study shows full effect of Pandemic Influenza H1N1 in New Zealand in 2009

A major new scientific study, estimates that 1.26 million or 29% of New Zealanders were immune to the pandemic influenza virus by March this year. But a large proportion of the population remain vulnerable.

 

Since the testing was completed many New Zealanders have also been immunised against pandemic influenza, however, given that there is still a large proportion of the population at risk from infection this winter, both influenza immunisation and basic measures to stop the spread of influenza remain important.

 

The Ministry commissioned study, conducted by ESR, estimates that of the 1.26 million people, about 480,000 people had some immunity prior to last year’s pandemic wave, mostly in the older age groups.

 

An additional 780,000 were estimated to have been infected during 2009. The highest rate of infection during 2009 was in school age children - where one in three children were affected. Almost half of those infected showed no obvious symptoms.

 

ESR’s national influenza centre head, Dr Sue Huang, said the rate of pandemic influenza A H1N1 infection during 2009 varied greatly by age – with the most surprising finding of the study being how many young people were affected.

 

“The high rate of transmission and infection among school-aged children was about ten times higher than we initially estimated based on clinical surveillance.

 

“This study confirms that the Pandemic Influenza is able to spread rapidly through communities. One of the more interesting findings was that it was a sub-clinical illness (i.e. no symptoms) for almost half of those who were affected. For most people their symptoms were mild, however, for many it was a very serious illness requiring an admission to intensive care,” Dr Huang said.

 

(Continue . . . )

 

 

The complete report (PDF File) is available on the New Zealand MOH website.

 

Seroprevalence of the 2009 influenza A (H1N1) pandemic in New Zealand

 

The study reflects the results of nearly 1700 blood serum samples taken between November 2009 and March 2010, along with another 521 sera collected pre-pandemic that were subjected to hemagglutination inhibition (HI) tests for antibodies to the 2009 H1N1 virus. 

 

A titer of 40 or higher was assumed to be seroprotective, and indicative of exposure to the virus or prior immunity.

 

Some selected excerpts from the study include:

 

• The  overall  community  seroprevalence was 26.7%  (CI:22.6-29.4)  for  the  study population.
• The seroprevalence varied with age and ethnicity. Children aged 5-19 years had the highest seroprevalence  46.7%  (CI:  38.3-55.0),  a  significant  increase  from  the  baseline  14.0% (CI:7.2-20.8). 
• This is followed by pre-school children aged 1-4 years at 29.5% (CI:21.2-38.0) an  increase  of  23.5%  from  a  baseline  of  6.0%  (CI:0.9-11.0). 
• Age  group  60+  had  no significant difference  in seroprevalence between  the serosurvey, 24.8%  (CI:18.7-30.9), and baseline, 22.6% (CI:15.3-30.0).
• Pacific Peoples had  the highest seroprevalence 49.5%  (CI: 35.1-64.0)  followed by Maori at 36.3%  (CI: 28.0-44.6).
• Based on the questionnaire survey approximately 45.2% of seropositive individuals had no symptoms giving an indication of a relatively silent spread of the disease in a naive population.

 

 

This study confirms the relatively low impact that the virus had on those over the age of 60, the pandemic’s heavy burden upon children and Pacific peoples, and provides us with a surprisingly high (45.2%) rate of asymptomatic infections.

Despite the high number of those infected, nearly 70% of New Zealand’s population appears still vulnerable to the virus.

 

I’ve only glossed over the highlights of this report.  There is much more to be gleaned here. 

 

Follow this link to read it in its entirety.

»» Read More

Australia’s Vaccine Shortage

 

 

# 4552

 

 

 

Flu season in the southern Hemisphere runs from around April to September, usually peaking in June or July.  

 

Despite the recent negative publicity surrounding a suspicious number of adverse effects among young children receiving CSL’s Fluvax, the demand for flu vaccine this year has been described as `unprecedented’. 

 

In fact, demand has outstripped supply, at least temporarily.   This report from the Herald Sun.

 

 

Victorians turned away because of shortage of seasonal influenza vaccine

Last Updated: May 07, 2010

THOUSANDS of Victorians wanting protection from influenza are being turned away by doctors because of a nationwide shortage of the seasonal flu vaccine.

 

As stocks run out, Victorian pharmacies have started waiting lists for people desperate to have the seasonal flu vaccine, which protects against swine flu as well as the two seasonal flu types A and B.

 

The main manufacturer of the vaccine, Australia's CSL, completed a fresh batch that was being rushed to wholesalers on Friday in the hope it would filter into the market over the next week.

 

A spokeswoman for the company warned there could be more shortages by the end of the month as overseas supplies were further delayed until June, leaving no time for CSL to produce additional stocks to fill the shortfall.

(Continue . . . )

 

 

The New Zealand Ministry of Health reports in their latest influenza update that the first shipments of European manufactured vaccine are now arriving, and advise that the recent shortages there may soon be coming to an end.

 

 

6 May 2010

Pandemic Influenza H1N1 2009 (swine flu) – Update 184

Surveillance data from GP practices and Healthline for the week ending 30 April shows a continued increase in both the number of people calling healthline for free health advice on influenza-like illness, and visiting the doctor with an influenza-like illness. While numbers are still below baseline, this continued increase could signal the start of a higher level of pandemic influenza activity in New Zealand.

<SNIP>

Vaccine Supply

Air freight is now returning to normal, following the widespread closure of European airports in mid-April caused by the eruption of Eyjafjallajökull in Iceland. Those airport closures created a backlog for air freight, which delayed the delivery of seasonal flu vaccine from France to New Zealand over the past few weeks.

 

Large shipments of vaccine are now possible, with the first (of 108,000 doses) arriving in New Zealand today (Thursday May 6).
This enables our seasonal flu vaccine stockpile to return to a state where it is well stocked - and in the next week will enable us to resume advertising to encourage people to access the protection provided by seasonal vaccination.

 

Having a healthy stockpile will also enable GPs and other key providers in the community to resume scheduling "vaccination clinics" - a practice we advised against in recent weeks when vaccines were in short supply.

»» Read More

New Zealand To Conduct Seroprevalence Studies

 

# 3954

 

One of the big unknowns about this pandemic virus is how many people are exposed to it, and develop protective antibodies, either with or without falling noticeably ill. 

 

The only way to tell is to do seroprevalence studies; taking blood samples from a representative group of a population and testing them for strain specific antibodies.  

 

New Zealand intends to do just that over the next couple of months, testing 2,500 people randomly selected from across that nation.  This is the kind of scientific study that will tell us a lot about this pandemic virus, and the answers will be eagerly awaited.

 

This media release from the NZ Ministry of Health.

 

 

Media Release

4 November 2009

Study to test pandemic influenza immunity

A study investigating the level of immunity New Zealanders have to pandemic influenza (H1N1) will get underway this month.

 

Blood samples will be taken from 2500 people to see who has been exposed to pandemic influenza and developed immunity to it. This information will be used to establish how many people are still at risk of contracting the illness.

 

The study is being undertaken by Environmental Science and Research (ESR) on behalf of the Ministry of Health.

 

Director of Public Health, Dr Mark Jacobs, says the health sector needs to find out what proportion of the population has already developed immunity to the virus so it can plan more effectively for a possible second pandemic wave.

 

“We know that many people had a mild to moderate illness as a result of pandemic influenza this winter, but we need to get a clearer picture of the general level of immunity and how many people are still at risk. This is because the smaller the proportion of New Zealanders infected so far, the higher the chance of a significant second wave happening in the future.

 

“This is an important study. We hope people will agree to take part in it if they are asked to do so,” says Dr Jacobs. “And people who take part will of course get to find out their own test result”.

 

A two week pilot study is expected to begin within the next few days at a single practice in the Hutt Valley. It will be followed by a nationwide study that will run from later in November until March next year.

 

People randomly selected from participating general practices throughout the country will be asked to take part.

 

The final report is expected in May.

»» Read More