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The Egyptian government has increased numbers of medical officers at Cairo Airport and will monitor passengers from Mexico during their stay.[53]

The government ordered the mass slaughter of all pigs in Egypt on April 29,[54] even though the current strain is a human-human transmittable, human influenza that has already previously hybridized with avian and swine flu.

[edit] Ghana

Ghana has banned the importation of pork and pork products.[55]

[edit] Nigeria

Nigerian Health Minister Babatunde Osotimehin said that the country is stockpiling antiviral treatments, informing the public and increasing surveillance.[53]

[edit] South Africa

On April 29, South Africa reported two possible cases of swine flu from two women who had recently travelled in Mexico.[56]

[edit] Zambia

An emergency task force has been set up by the Zambian government.[53]

[edit] Asia

[edit] Azerbaijan

On April 27, Azerbaijan imposed a ban on import of animal husbandry products from America.[57] According to the Chief of the State Veterinary Service under the Agriculture Ministry Ismayil Hasanov, products brought to the country by April 27 received certificates and it was confirmed that those products were safe.[58] 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.[59]

Azeri Minister of Health Ogtay Shiraliyev said the order prepared by him considers implementation of necessary measures in the epidemiological and various medical centers. "Azerbaijan is ready for this issue", he said.[60] According to the Agriculture Minister Ismat Abbasov, the State Veterinary Service is holding monitoring in the regions and pigs are kept in closed places in farms.[57] Abbasov also said: "I can say with full responsibility that the situation on prevention against swine flu virus is stable in Azerbaijan".[57]

[edit] Bangladesh

Medical officers, representatives from the WHO and International Centre for Diarrhoeal Diseases Research are stationed at airports and all travellers, particularly from affected countries, are to be screened.[53]

[edit] Cambodia

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.
"We are very worried about this new disease because it can transfer from pig to human, from human to human and from human to pig," Khlauk Chuon added.[61]

[edit] China

The General Administration of Quality Supervision, Inspection and Quarantine (AQSIQ) of China issued an emergency notice on the evening of 26 April that visitors returning from flu-affected areas who experienced flu-like symptoms within two weeks would be quarantined.[62] The Ministry of Health has started prevention measures, and initiated cooperation with the WHO and the relevant departments of the Mexican and U.S. governments to help contain the outbreak. According to Wang Jing of the China Inspection and Quarantine Science Research Institute, the measures already in place in China against bird flu are sufficient for this new disease.[63]

[edit] Hong Kong

The Food and Health Bureau of Hong Kong issued a travel advice for Mexico on 26 April, 2009, that advised Hongkongers not to travel to Mexico unless it is absolutely necessary.[64] The Bureau also escalated the alert level to "Serious" on the same day,[65] which activated health protection measures in all port of entries 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.[64] Hong Kong also became one of the first cities to declare the swine flu as a notifiable disease.[66][67]

The Secretary for Food and Health Dr. York Chow states that special attention will be paid to passengers who come from countries where human infection of swine influenza cases have been reported.[65]

As of 30th April 2009, according to the Hong Kong government, there are no confirmed human case of swine influenza A (H1N1) infections in Hong Kong. There were 9 patients fulfilled the designated reporting criteria, 8 of which tested negative in swine influenza and 1 patient are still under isolation and pending results of laboratory.[68]

[edit] India

The Government of India has decided to screen all people entering India via the main airport hubs of Mumbai, New Delhi, Goa, Jaipur, Kochi, Chennai, Bangalore and Hyderabad. It said the primary focus will be on passengers entering from the United States of America, The United Kingdom, Canada, Mexico, France, and New Zealand. A team of 32 highly skilled medical professionals have been posted at these airports. The Ministry of Health is also trying to track down people who have entered India from Mexico in the last 10 days.[69] It has been reported that one person recently traveled from Texas to Hyderabad with flu symptoms and was quarantined, but authorities refused to divulge his identity.[70] Government health officials & WHO subsequently stated that there is no Swine flu in India and the said patient recovered from a common cold.[71]

[edit] Indonesia

After a coordination meeting about the flu on April 27, 2009, the Indonesian government halted the importation of pigs and initiated the examination of 9 million pigs in Indonesia.[72] Thermal scanners which can detect human body temperature have been installed at Indonesian ports of entry. Temperatures above 38 degrees Celsius (100.4 Fahrenheit) cause the devices to beep, indicating fever. The devices have been installed in Soekarno-Hatta International Airport and Halim Perdana Kusuma Airport in Jakarta, Juanda Airport in Surabaya, Hang Nadim Airport in Batam, Hasanudin Airport in Makassar, Ngurah Rai Airport in Denpasar, Sepinggan Airport in Balikpapan, and Tanjung Priok Seaport, gates one and two in Jakarta.[73]

[edit] Israel

Two cases have been confirmed in Israel, and one more is suspected.[74] In response to the outbreak, the Israeli Deputy Minister of Health, Yaakov Litzman, has said that because swine are unclean, the outbreak needs to be renamed, and so in Israel, out of respect for the religious sensibilities of Jews and Muslims, it 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.[75][76] but the Israeli government retracted this proposal following Mexican complaints.[77]

[edit] Japan

The Ministry of Agriculture, Forestry and Fisheries of Japan instructed animal quarantine offices across Japan to examine any live pigs being brought into Japan to make sure they are not infected with the influenza.[78] Japanese Agriculture Minister Shigeru Ishiba appeared on television to reassure customers that it was safe to eat pork.[79] 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.[80]

[edit] Kyrgyzstan

All meat imports from the United States and Mexico have been banned temporarily.[53]

[edit] Laos

The Lao government agreed to buy 10 thermal imaging machines and install them at the country's major immigration border checkpoints. The machines would help officials identify anyone entering the country with a high temperature and create confidence among Lao people, foreigners living in Laos and people traveling to Laos. Health officials would be on hand at international border checkpoints to ensure anyone found to be infected could be treated immediately. Each machine could cost about US$25,000. The decision to buy them was made after the government found visitors to Laos included people coming from the United States , Spain and other affected countries.
The Prime Minister said masks should be made available and health officials would be assigned to work at border checkpoints. The machines would help officials identify anyone entering the country with a high temperature and create confidence among Lao people, foreigners living in Laos and people travelling to Laos. Health officials would be on hand at international border checkpoints to ensure anyone found to be infected could be treated immediately.[81]

[edit] Lebanon

The Lebanese Health Minister Mohammad Khalifeh 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.[82] Beirut also banned the import of pork.[83]

[edit] Malaysia

According to the Malaysian Health Ministry, health screenings will be carried out on passengers traveling to and from Mexico beginning on April 17.[84] The Health Ministry’s disease control division has activated its operations room to monitor the swine flu situation and informed medical practitioners who are treating cases with symptoms of influenza-like illness or severe pneumonia and persons who had visited Mexico, California or Texas to inform the district health office immediately for preventive and control measures.[85]

[edit] 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.[86]

[edit] Nepal

All visitors from the United States and Mexico will be screened and medical officials are stationed at Tribhuvan International Airport.[53]

[edit] Pakistan

Pakistan has taken precautionary measures at the international airports to check passengers coming from swine flu affected countries.[87] 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.

[edit] Philippines

Philippines' Health Secretary Francisco T. Duque III has ordered the Bureau of Quarantine to use thermal imaging equipment at airports to screen passengers coming from the US for flu symptoms.[88] The Philippines may quarantine travelers arriving from Mexico with fevers.[89] Also, the Secretary of the Department of Agriculture of the Philippines issued an order banning the importation of hogs from the U.S. and Mexico, and the retraction of the restriction of swine influenza vaccine use.[90]

[edit] Saudi Arabia

In the Kingdom of Saudi Arabia all airports and borders, both land and sea, are being installed with thermal cameras to monitor the incoming passengers, announced the ministry of health and quarantine officials at airports and seaports have been instructed to be on alert to check passengers who come from infected countries for fever until all the digital surveillance starts. Beginning next week, the ministry would launch a nationwide awareness campaign, Health Ministry spokesman Khaled Mirghalani said.[91] Flights from affected countries have also been halted as a precautionary measure.[92]

[edit] Singapore

Singapore's Minister of Health Khaw Boon Wan has urged citizens to limit travel to affected areas such as Mexico and the United States. The Health Ministry has advised the public to seek immediate medical attention if they experience influenza symptoms within seven days after arriving from affected areas, to maintain good hygiene, and for those who are sick with respiratory illnesses to avoid crowded areas and wear masks.[80]

On 28 April, Singapore's Ministry of Health raised its Disease Outbreak Response System to a Yellow alert, the second level of a 5 colour alert scale.[93] Medical staff working at critical areas such as Emergency Departments (EDs) and Intensive Care Units in hospitals have been advised to don full Personal Protective Equipment (PPE). Patients with flu-like symptoms and who have a travel history to affected areas or contact with someone who has will be isolated within the hospitals. There is also a system for patients visiting outpatient clinics so as to avoid transmission. Elective admissions have been rescheduled, the number of visitors to patients have been cut down, and contact particulars of visitors are recorded so as to help reduce unnecessary exposure, provide for surge capacity and to facilitate contact tracing when the need arises.[94]

On 30 April, the Disease Outbreak Response System was raised to an Orange alert, the third level of a 5 colour alert scale.[93] Additional measures include temperature screening and screening for flu like symptoms for visitors to clinical care areas. Hospital staff is now required to don PPE in all areas with patient contact. Patients in hospitals would be restricted to one visitor at a time so as to facilitate contact tracing and reduce unnecessary risk of exposure. [95]

Those who have been to Mexico in the past 7 days would be quarantined for 7 days when they enter Singapore and undergo phone surveillance for symptoms of swine flu. Those who develop symptoms will be referred to the CDC for a thorough assessment. [95]

On 30 April, 22 people were tested for the virus, 21 came back negative and one is still pending.[96]

[edit] South Korea Dokudo ilands

South Korea warned against travel to Mexico City and three Mexican states.[79] 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.[62] 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.[97] Several surces have informed that one case has been confirmed by lab in South Korea, on April 30.[98][99]. However, at the time, no other source has confirmed that information.

[edit] Republic of China

Although no cases of the influenza have been reported in the Republic of China (ROC), the government has already taken several steps to prevent the possible outbreak of Swine Flu, including a command center set up, travel alerts for infected nations,[79] and more severe health check been conducted at international ports. Taiwan said visitors who came back from affected areas with fevers would be quarantined.[100] 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.[79] 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.[79]

[edit] Thailand
Travelers are being scanned at Suvarnabhumi Airport to prevent the spreading of swine flu

The Thai Government has installed thermal scanners in Suvarnabhumi Airport and other key airports. Airport health officials began using thermal screening equipment to monitor passengers arriving from the southern United States and Mexico for flu-like symptoms including fever to prevent spreading Mexican flu. Each unit comprises an infrared thermal camera, a processor and a monitor to show the results of readings. Public Health Minister Witthaya Kaewparadai told in a press conference that all visitors arriving at Thai airports would be required to be scanned by thermal scanner. Initially only visitors from affected countries such as US, Canada and Mexico, were required to walk past the scanners. Travelers found with suspicious flu symptoms that could develop into Mexican influenza will be asked to undergo treatment at one of seventeen state hospitals. The hospitals are on full flu alert and they will be assisted by the private sector. Medical instruments and drugs are ready to support the operation. On the April 28, 2009, the Thai Public Health Ministry issued a warning for Thais to avoid visiting the United States and Mexico which have been hit by the Mexican Flu. The Thai cabinet has formed a national emergency committee to oversee prevention operations against the Mexican flu, Prime Minister Abhisit Vejjajiva said.[101][102] An initial test on a 42-year-old woman who had flu-like symptoms after returning from a trip to Mexico and the US between April 3 and 19 proved negative. She was admitted to Chulalongkorn Hospital after having a fever since Thursday when she travelled to Singapore.[103]

Public Health Minister Witthaya Kaewparadai instructed provincial public health offices to stock up influenza drug to cope with possible outbreak of the Mexican flu. Witthaya said he had instructed chief provincial public health officers nationwide to check stock of Oseltamivir anti-viral drug, used for influenza treatment, in their provinces and make sure the drug is available.[104]
Bangkok governor Sukhumbhand Paribatra will hand out a hundred thousand free face masks to taxi drivers and tourists in Bangkok in an effort to prevent Mexican flu from spreading to the Thai population, deputy governor Malinee Sukavejworakit said. The gauze masks would be handed out to foreigners staying at guesthouses. The Bangkok Metropolitan Administration (BMA) is also encouraging taxi drivers to wear face masks while driving passengers. General public could go and get free masks at the BMA on Friday.[105]
Thailand will send 5,000 face masks and hand washing gels to Mexico which has been hard hit by Mexico human flu, Foreign Ministry's spokesman Tharit Jarungwat said Thursday. The Thai embassy in Mexico will distributed the masks and the gels to Thais living there, he said.[106]

Five Thai workers who returned from Singapore Wednesday night (April 29, 2009) will be monitored by health officials for 14 days although they show no sign of flu, Public Health Minister Witthaya Kaewparadai said. The five were allowed to return home after they showed no sign of flu but they needed to be monitored by health officials for 14 more days.[107]

[edit] Vietnam

Vietnam's Ministry of Health released an emergency dispatch and urged agencies to take precautionary measures against swine flu. In addition, the Preventive Health and Environment Bureau requested all health facilities to carefully monitor any suspected H1N1 case and Bureau head Nguyen Huy Nga also warned that the pandemic could enter Vietnam through imported swine or border gates.[108] Thermal imaging devices were dispatched to airports and border gates to screen passengers.[109] 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.[110]

[edit] Europe
Outbreak evolution in Europe:
Confirmed cases Unconfirmed or suspected cases

[edit] European Union

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.[111]

EU Foreign relations commissioner Benita Ferrero-Waldner said on April 29 the halt of all travel to Mexico and disinfecting all airports due to the global flu outbreak is being considered.[112]

[edit] Austria
Outbreak evolution in Austria:
Confirmed cases

Several possible cases in Austria turned out to be negative, whereas one test, that of a 28-year-old woman from Vienna, had a positive result. Therefore Austria is the 9th country affected by a confirmed case of swine flu.[113] There are still two suspected cases being tested. [114]

[edit] Belgium

Six suspected cases of swine flu in Belgium ultimately tested negative.[115]

[edit] Croatia

On April 29 it was announced that a 22-year old traveller from Florida had been held in quarantine in Osijek under suspicion of swine flu.[116] However, later that day director of infectious disease epidemiology agency, dr. Ira Gjenero Margan, stated results of the testing were negative "with 99% certainty".[117] On April 30, a child was held in quarantine in Zagreb but the results were negative.[118]

[edit] Finland

Two suspected cases were announced. The first suspected case is being investigated in Lahti, the patient returned from Mexico with flu symptoms. The patient has now been released from hospital as the initial results for swine flu were negative. However, she is self-quarantined at home until final results will come.[119] The second suspect, who recently returned from Spain, is being investigated in Kotka.[120] The H1N1 strain of influeza has been added to the official list of infectious diseases dangerous to public ("yleisvaarallinen tartuntatauti" wink , which guarantees free-of-charge treatment to all residents and allows for involuntary quarantine, effective from 1st May 2009.[121] Both of the cases were false alerts.[122]

[edit] France

As of April 28 there were twenty suspected cases of swine flu being investigated in France. Since April 25, over 100 cases of Influenza-like illness have been reported, of which 30 were identified as possible cases. 10 of those cases have since been excluded.[123] On April 29, the number of suspected cases was revised to 25.[124]

[edit] Germany
Outbreak evolution in Germany:
Confirmed cases Unconfirmed or suspected cases

Two men and a woman from Bielefeld who had been suspected of having the virus tested negative on influenza type A.[125]

On April 29, the first case of swine flu in Germany was confirmed by the Robert Koch Institute in the area of Regensburg.[126][127][128] A 22-year-old woman from Hamburg is confirmed to have been infected by swine flu during a trip to Mexico.[128] A 37-year-old woman from Kulmbach is also confirmed to have become infected during a similar trip.[128] Further suspected cases are in examination.[128]

[edit] Hungary

According to the MTI as of 29 April six suspected cases have been reported in Hungary, none of them confirmed to be the swine flu. Samples of the virus from the US health authorities are due to arrive to Hungary in a few days enabling the start of vaccine production.[129]

[edit] Iceland

Iceland is currently being briefed by the WHO and is cooperating closely with ECDC, CDC and the EU in terms of monitoring and response Initially the directorate of health warned people traveling to Mexico and the United States (especially California and Texas) to exercise caution and to contact a doctor immediately if they started showing symptoms of swine flu but on April 28 people traveling to Mexico were advised to cancel their trip unless its very urgent.[130][131]

On April 28 it was announced that passengers arriving in Iceland from the United States or Mexico would be monitored and will undergo medical examination even if the slightest signs of influenza are detected.[132]

On April 28 Haraldur Briem, Head of Infectious Disease Control, announced that two individuals arriving from the United States will be undergoing medical examination because of discomfort and vague symptoms. He added that its unlikely that they are suffering from swine flu.[133] On April 29 it was announced that the case of the two individuals arriving from the United States had been a false alarm and that they did in fact not have the swine flu.[134]

Iceland has stocks of Tamiflu and Relenza for one-third of its population.[132]

In a risk assessment made by the Icelandic government in 2008 in case of a influenza pandemic two scenarios are envisioned:

* A worst-case scenario where 50% of the Icelandic population are infected and 3% of the infected population die.
* A milder scenario where precautionary measures prevent infection, 25% of the Icelandic population are infected and 1% die.[135]

[edit] Ireland

Initial fears about four Irish people with symptoms proved negative, but three more could have to go through tests within the next few days.[136]

Ireland has over two million doses of anti-virals (Tamiflu and Relenza; enough for half the population) and a pandemic plan in place should the outbreak reach the country.

On 29 April, 2009, notices were put in place at Irish ports and airports offering advice to people returning from countries affected by the swine flu virus.[137]

On 30 April, 2009, the Department of Health's Chief Medical Officer, Doctor Tom Holohan, announced the first probable confirmed case in Ireland. The case is an adult male living in the east of the country who had recently been to Mexico. He has been on anti-viral treatment as have any people he has come into close contact with as a precaution.[138]

[edit] Italy
Outbreak evolution in Italy:
Unconfirmed or suspected cases

Italy's agriculture lobby, Coldiretti, warned against panic reaction, noting that farmers lost hundreds of millions of euros due to consumer boycotts during the 2001 mad cow scare and the 2005 bird flu outbreak.[139]

A woman who returned from San Diego was hospitalised in Venice for suspected swine flu.[140]

As of April 30, about 20 suspected cases of swine flu are monitored in Italy.[141]

[edit] Lithuania

As of April 29, one possible case (tourist returned from Mexico) in Lithuania is currently under investigation. The institutions already confirmed that it is the A type influenza, but the details as to whether it is H1N1 are still not known.[142] For further investigation sample was sent to the laboratory located in London.[143]

[edit] Macedonia

On April 27 2009, the government of the Republic of Macedonia prohibited all exports and imports of live pigs. Even though Macedonia is not affected from the Swine Flu, the government ordered a ten days health monitoring period for everybody that comes from an affected country.[144]

[edit] Netherlands

The Netherlands National Institute for Public Health and the Environment advised any traveller who returned from Mexico since April 17 and developed a fever of 38.5 degrees Celsius (101.3 degrees Fahrenheit) within four days of arriving in the Netherlands to stay at home.[89] On April 30, 2009 a three year old child tested positive for the swine flu. The child returned from Mexico to the Netherlands on April 27, 2009. The parents tested negative to the swine flu. The child is doing well.[145]

[edit] Norway

As of April 28, three persons have tested negative for swine flu.[146] Test results are not yet in for a two year old boy from Revetal, Vestfold, who returned from vacation in Mexico with flu-like symptoms.[147]

The Norwegian government projects that in the worst case, 1.2 million Norwegians may fall ill and 13,000 may die.[148]

[edit] Poland

As of April 30, four cases are currently under investigation.[149] Several other patients had been previously investigated but tests turned out negative.[150][151] The Polish Foreign Ministry issued a statement recommending that citizens avoid travel to affected areas until the outbreak is totally contained.[89]

[edit] Portugal

As of April 29, there has been one suspected case in Portugal, according to Reuters.

[edit] Romania

In Sâmbăteni, Arad County, a child of a year and six months and his mother who recently returned from a trip to Portugal and Spain were suspected of having contracted Swine Flu. Tests returned negative.[152][153]

[edit] Russia

Russia has banned the import of pork meat from Guatemala, Honduras, Dominican Republic, Colombia, Costa Rica, Cuba, Nicaragua, Panama, El Salvador, 9 US States (Alabama, Arizona, Arkansas, Georgia, Kansas, Louisiana, New Mexico, Oklahoma and Florida) and all types of meat and meat products from Mexico and 5 US States (California, Texas, Kansas, New York and Ohio).[154][155][156]

The President instructed the regional governors to take urgent steps to prevent swine flu from spreading to Russia. Mr Medvedev also instructed the presidential plenipotentiary envoys in the federal districts to personally supervise the preventive measures to ensure the disease did not spread [in Russia] and stipulated monthly reports on the situation.[157]

[edit] Serbia

According to Deputy Health Minister Svetlana Mijatović, Serbia will adhere to all WHO recommendations for monitoring the swine flu epidemic.[158] "A sanitary inspection, together with Serbian Ministry of Internal Affairs (MUP), is checking travelers, [...] while the media and all the agencies throughout the world, as well as our own, are constantly informing the public that if anyone feels ill, or is coming from a contaminated area, to consult the authorities at any airport in the world [...]," Mijatović said.[158]

Flights and holidays to Mexico and the U.S. have yet to be canceled, and the advice to citizens traveling to infected countries is to take precautions in terms of immunity and to maintain personal hygiene.[158]

A 71 year old tourist from Texas asked to be tested for swine flu at the Provincial hospital in Novi Sad, on April 30. Results were negative.[159]

[edit] Spain
Main article: 2009 swine flu outbreak in Spain
Confirmed cases Unconfirmed or suspected cases

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.[160]

The Spanish government is also observing other 35 possible swine flu cases in the Basque Country, Catalonia, the Balearic Islands, Andalusia, Murcia, Madrid and the Valencian Community.[161]

AENA, the Spanish state owned company who manages all Spanish airports and Air Traffic Control established a protocol for the flights coming from and to Spain from the affected areas.[162] Three patients who had just returned from Mexico were under observation in multiple regions of Spain.[139]

[edit] Sweden

On April 28, at least eighteen Swedish people were tested for swine flu after returning from trips in Mexico and the USA, but the results were negative.[163] [164]

[edit] Switzerland
A map about The N1H1 in Switzerland.
Confirmed cases Unconfirmed or suspected cases

The first suspicious case was officially confirmed on April 27. A young man returning from holiday in Mexico informed his family doctor about fever and flu-like symptoms. He was immediately put under quarantine in a hospital. 8 more people are under observation. A container of inactive swine flu virus samples packed in dry ice exploded on a Swiss train, injuring one person but posing no other risks to humans.[165]

Switzerland has confirmed its first case of swine flu in a 19-year-old student who returned from Mexico on April 30. The state hospital in Baden said in a statement that the National Influenza Center in Geneva confirmed the disease shortly after the student was mistakenly released from hospital day before.[166]

[edit] Ukraine

Imports of pork and live pigs from all affected countries have been banned. The ban also applies to all shipments after April 21.[53]

[edit] United Kingdom
Main article: 2009 swine flu outbreak in the United Kingdom
Confirmed cases Suspected Cases

On April 25, 2009, a member of British Airways cabin crew was taken to Northwick Park Hospital in Harrow and quarantined after falling ill with flu-like symptoms on a flight from Mexico City though he was later found not to have swine flu.[167]

On April 26, two people were admitted to hospital in Scotland suffering from mild flu-like symptoms after returning from Mexico, later confirmed as swine flu.[168] The Scottish Health Minister reported that seven of the 22 people who were in "close contact" with the two confirmed Scottish cases after they returned home were showing flu-like symptoms.[168] Four people were given medication and advised to stay in their home in Stanwick, Northamptonshire, again after returning from Mexico with mild flu-like symptoms.[169]

On April 27 the UK Health Secretary Alan Johnson told the House of Commons that 25 possible cases had been reported. He also stated that protective facemasks were not planned, as despite their use in Mexico, scientific evidence did not suggest that they proved an effective preventative measure.[170] On the same date, passengers were held on planes arriving at Heathrow, from Mexico City, whilst officials carried out health checks.[171]

On 29 April the government officially made public three more confirmed cases in the UK. These were two adults (one in Redditch, and one in London), and a 12-year-old girl in Torbay, Devon. All three new cases had recently arrived back from Mexico.

As of late April 2009 Britain has a stockpile of about 33 million courses of antiviral drugs effective against this strain.[citation needed] There is a pandemic plan covering topics from distributing the drugs and setting up helplines to closing schools and banning public events which was tested in a large exercise in 2007.[172]

On 30 April Three new cases of swine flu were diagnosed in the UK, bringing the total number to eight, the Department of Health has confirmed. Two of the cases are in London and one in Newcastle, where two students who shared a house with the patient are now being treated with an antiviral drug. The unidentified person recently returned from a trip to Mexico.

[edit] North America

[edit] Aruba

Trevor van Gellecum, the Director of the Aruban Department of Health, announced that all passengers arriving by airplane or cruise ship will have to fill out a health questionaire beginning on April 27, 2009.[173] Hotels and resorts are required to report to authorities if any tourists are showing flu-like symptoms.[173] The government of Aruba also ordered antiviral medication and other supplies from the Netherlands and the United States.[173] No swine flu cases have been reported.[173]

[edit] Bahamas

10 students and teachers who arrived from Mexico at the beginning of the week are in Quaranteen. [174]

[edit] Barbados

The Minister Of Health, Donville Inniss has confirmed that 2 samples have been sent off to the Caribbean Epidemology Cantre in Trinidad and Tobago to be tested for the virus. [175]

[edit] Belize

There are two suspedted cases of Swine flu currently under investigation in Belize. As a result all major public events have been cancelled. This includes the National Agriculture and Trade Show. [176]

[edit] Canada
Main article: 2009 swine flu outbreak in Canada
Outbreak evolution in Canada:
Confirmed cases Unconfirmed or suspected cases

As of April 30, twenty-seven cases of swine flu have been confirmed in the country, eight in Nova Scotia, seven in Ontario, six in British Columbia and six in Alberta.[177][178][179][180] Nova Scotia's chief medical officer, Dr. Robert Strang, said on 26 April that the National Microbiology Laboratory in Winnipeg confirmed late the previous day, that four young people in the province were recovering from "relatively mild" cases of the disease. The four all attended King's-Edgehill preparatory school in Windsor; and one of the four infected students had been on a recent school trip to the Yucatán Peninsula.[177][181] There is evidence that the disease is spreading beyond the first 4 Nova Scotia cases, as friends and relatives are starting to show symptoms. Dr Robert Strang indicated that he expects the disease to spread to the rest of Nova Scotia within a few weeks[182]

Dr. Michael Gardam, director of infectious disease prevention and control at Ontario's public health agency, said in an interview with the CBC that an outbreak of swine flu in Ontario, Canada's most populous province, would not be as serious as the 2003 SARS epidemic.[183] In preparing for and dealing with an influenza pandemic, the Public Health Agency of Canada follows the WHO's categories, but has expanded them somewhat.[184] Despite initial reports of two swine influenza cases in a Montreal hospital, an official on the Montreal regional health board confirmed negative results for all quarantined patients at the hospital and that no quarantines were currently in effect at the hospital.[185]

Canada's Chief Public Health Officer, Dr. David Butler-Jones, stated that the six affected Canadians suffered from only mild symptoms and have already started to recover. Butler-Jones warned against complacency though, stating that the fact that only mild cases have been reported so far "doesn’t mean we won’t see either some more severe illness or potentially deaths."[186] In both provinces, the cases either involved people who had recently returned from Mexico or those in close contact with them.[187]

[edit] Costa Rica

A 21 year old woman was confirmed as carrying the swine flu virus on April 28. The woman, whose identity and location is kept hidden, came back from Mexico by airplane. Local authorities are tracking back all possible occupants of the same or related flights.[188] A second case was confirmed on the same day, a 30-year old man who traveled to Mexico the week before.[189]

[edit] Cuba

Cuba's Health Ministry is adopting precautionary measures to prevent the illness from coming into the country. The government has advised citizens to go to seek medical treatment if experiencing flu-like symptoms.[190] Cuba has also banned flights to and from Mexico for 48 hours.[191]

[edit] Guatemala

A 29-year-old, who had recently visited Mexico, was being tested for a suspected case of swine flu.[192]

Guatemala is checking all travelers arriving from Mexico for signs of flu and stopping anyone with symptoms of the virus at border crossings.[192]

[edit] Honduras

There are a number of suspected cases in Honduras. There are 15 suspected cases, none of which have been confirmed. [193]

[edit] Jamaica

There has been no reports of the 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.[194]

[edit] Mexico
Main article: 2009 swine flu outbreak in Mexico
Outbreak evolution in Mexico:
Deaths Confirmed cases

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.[195][196] As of April 26 there had been 1,614 cases, with 103 deaths and about 400 patients in hospital; approximately two-thirds of the sick patients had recovered.[197]
Mexican soldiers distributing protective masks to citizens

Soldiers mobilized by the government have handed out six million surgical masks to citizens in and around Mexico City.[198] 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.[199] 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.[200] José Ángel Córdova, federal Secretary of Health, said on April 24 that schools will probably be suspended for at least the following week then, and that it will take around ten days to see the evolution of the virus' behavior, and to consider other measures after such.[201] On April 25, President Felipe Calderón declared an emergency which granted him the power to suspend public events and order quarantines.[202] Hours later, Córdova announced that classes in Mexico City would be officially suspended through May 6.[203] On 26 April, Natividad González Parás, governor of the northeastern State of Nuevo León, announced that state-wide schools will remain closed until 6 May, and established a quarantine system in airports, central bus stations and the creation of observation points mainly in the southern part of the state at the nearest highways to the borders with other states, in order to realize tests conducted on people arriving from other states. However, as for April 27, there are no confirmed reported cases of infection in this state.[204]

On 26 April, 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.[198]

On 27 April, the Secretariat of Public Education announced that all schools in Mexico will remain closed at least until May 6.[205]

On 28 April, 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.

[edit] Trinidad and Tobago

The members of the Under 17 Trinidad and Tobago football team have taken Flu tests after returning from a World Cup qualifying football match in Mexico City.[206]

[edit] United States
Outbreak evolution in the United States:
Deaths Confirmed cases Unconfirmed or suspected cases
Confirmed human cases with known dates of illness onset (USA, April 27, 2009).
Main article: 2009 swine flu outbreak in the United States

Officials in the United States confirmed that seven people in California, two students from a high school in Texas, and a married couple in Kansas were infected with the A/09(H1N1) swine flu; all have recovered.[207] One additional student from the same high school in Texas is suspected of probably having the influenza strain. One student in Hawaii who recently visited Mexico City is suspected of having the flu, while both a male and female friend of the student, a couple, are suspected of also having the disease. St. Francis Preparatory School, a private school in New York, has 28 confirmed cases of swine flu.[208] The cases in Kansas and New York are linked to travel to Mexico; most of the cases in California and Texas are not linked and may reflect localized outbreaks of this virus in those areas.[209] One case has been confirmed in Elyria, Ohio.[207] A public health emergency has been declared, but it was said that this is standard procedure in cases as divergent as the recent inauguration and flooding.[210]

The United States of America has declared a state of Public Health Emergency. According to the New York Times, "the emergency declaration frees resources to be used toward diagnosing or preventing additional cases and releases money for more antiviral drugs," including the transfer of approximately 12 million influenza medications from a federal stockpile to states.[198][211] The U.S. plans to follow a guidebook developed over the past five years to fight a pandemic flu, such as H5N1. The situation has developed rapidly with the White House initially looking into the matter according to press releases on April 24, but rapidly adopting a more serious stance as the WHO and CDC issue stronger recommendations.

On April 28, the US suffered its first confirmed death of swine flu. The Centers for Disease Control and Prevention officially confirmed through tests that a 23-month old child died due to the flu. The child was a resident of Mexico who had come to Brownsville, Texas to visit relatives and was initially treated for pneumonia on April 13. When the sickness continued to worsen the next day, he was transferred to Texas Children's Hospital in Houston.[212][213][214]

[edit] Oceania

[edit] Australia

As of 28 April 2009, Australia has reported at least 128 suspected cases of swine flu that are being tested. Australia has a stockpile of 8.7 million doses of Tamiflu and Relenza.[215] Airlines have been required to report passengers from the Americas with influenza symptoms, and nurses have been deployed at international airports.[215]

[edit] Fiji

Fiji on Wednesday moved to high alert against the swine flu virus, with the authorities admitting the Pacific island nation was not immune to the rapidly spreading global threat.[216]

On Thursday April 30, 2009, a traveller suspected of being infected by the swine flu virus is under close surveillance at Lautoka Hospital, said the Health Ministry.[217] Hours later, the Health Ministry said there are two suspected cases. [218]

[edit] French Polynesia

French Polynesia has reported no cases of swine flu so far.[219] Officials installed a thermal imaging camera on April 27, 2009, at Faa'a International Airport in Tahiti to screen all arriving international passengers.[219] French Polynesia has 48,000 Tamiflu anti-viral treatments available in case of an outbreak,[219] and more can be flown into Tahiti within twenty-four hours.[219]

[edit] New Zealand

The impact in New Zealand has been almost negligible with no fatalities reported in this country.

Following a three-week language trip to Mexico, ten students from Rangitoto College, a secondary school in North Shore City, Auckland, exhibited influenza symptoms. All 22 students and three accompanying teachers from the trip are currently in home isolation, with oseltamivir provided to the patients and those in contact with them. Ten students tested positive for an influenza A virus,[220][221] with three of them later testing positive for swine flu.[222] The symptoms are reportedly mild and all affected individuals are recovering.[223] A further five people are being tested for influenza A.[224]

New Zealand has a well developed Influenza Pandemic action plan.[225] New Zealand has upgraded its influenza pandemic alert status to code yellow.[226] The national stockpile of 1.4 million doses of oseltamivir has been released to regional health authorities. New Zealand is currently following a policy of border control and cluster control via voluntary quarantine and treatment of contacts with oseltamivir.

New Zealand typically has over 40,000 cases of all types of influenza each year – almost half of which are strain A – with approximately 100 deaths a year directly attributed to influenza viruses.[227] In the 1918 Spanish Flu outbreak, over 8600 people died in New Zealand.[228]

[edit] Palau

Palau has issued a health alert for swine flu.

Health Minister Dr. Stevenson Kuartei told reporters that although there is no reported case in Palau, a Task Force has been convened to increase screening of passengers entering the country.[229]

[edit] Papua New Guinea

National Agricultural Quarantine and Inspection Authority (NAQIA) chief quarantine officer of animals, Dr Nime Kapo, said that the Health Department was keeping an eye on the situation, and that a national contingency plan would be announced soon.[230]

[edit] Solomon Islands

A multi-sectoral task force has been activated by the Solomon Islands Ministry of Health to deal with the deadly swine influenza virus.

Permanent Secretary of the Ministry of Health and Medical Service Lester Ross said a task force is managing the Solomon Island Ministry of health's response to recent threat of swine flu epidemic.[231]

[edit] Tonga

Tonga has set up an Emergency Taskforce and is performing screen checks at its International Airport for passengers experiencing influenza symptoms, most importantly from flights originating from Los Angeles.[citation needed]

[edit] South America
Outbreak evolution in South America:
Confirmed cases Unconfirmed or suspected cases

[edit] Argentina

According to an Epidemic Alert order issued by the Ministry of Health, Airlines have been required to report passengers with influenza symptoms arriving from Mexico and United States. Passengers from these countries must fill out a form to be located should they experience any symptoms.[232] In addition, the government has also stepped up safety checks, and thermal scanners are being used on airports to detect passangers with fever and other influenza symptoms. As of April 28, the Government has suspended all flights originated from Mexico until May 4 as a precautionary measure.[233]

4 cases are being studied under isolation as possible swine flu infections. Health Authorities have also informed that 21 earlier suspected cases were dismissed.[234]

[edit] Bolivia

A "state of health" alert has been declared and health service workers will be transferred to airports and border areas if an outbreak occurred.[53]

[edit] Brazil
Outbreak evolution in Brazil:
Unconfirmed or suspected cases

Two people who had arrived in Brazil from Mexico with symptoms of an undefined illness were hospitalized in São Paulo on April 25. It was initially suspected that they were suffering from the swine flu virus.[235] The Brazilian Ministry of Health later issued a press release stating that while the exact cause of the two patients illnesses remained unknown, they "did not meet the definition of suspected cases of swine influenza because they did not have signs and symptoms consistent with the disease: fever over 39 °C, accompanied by coughing and/or a headache, muscle and joint pain."[236]

The press release also stated that airports would monitor travelers arriving from affected areas, under the direction of the National Sanitary Surveillance Agency (ANVISA). Air crews are also being trained on signs and symptoms of swine influenza so that passengers displaying symptoms may receive guidance from ANVISA upon arrival.

On April 27, a person who had arrived in Salvador, Bahia, from the United States was hospitalized.[237]

[edit] Chile

On April 27, the Assistant Secretary of Health Jeanette Vega, confirmed that there are eight suspected cases of swine influenza in the country, which are being examined at the Hospital del Tórax in Santiago. Five other cases have been dismissed by the authorities.[238]

On April 28 the Health Ministry announced 26 cases under investigation: 16 in Santiago; 2 in Atacama; 2 in Valparaíso; 4 in O´Higgins Region; 1 in Biobío and 1 in Araucanía. 16 other cases have been dismissed.[239]

[edit] Colombia

The Minister of Social Protection, Diego Palacio Betancourt, announced on April 26, 2009, that 12 suspect cases had been detected, 9 in Bogotá and 3 on the Caribbean coast. Samples of the virus have been sent to the USA for comparisons and analysis. Results of the testing are expected in a few days. On April 27, the Government declared a "national disaster" state[240] in order to face the emergency, which allows health authorities to have a special budget to do so.[241] As of April 28, most of the suspect cases were excluded, with only four remaining: three Mexican teachers in Bogotá, and one person in Cartagena.[242] Another 38 suspect cases were under observation.[243] On April 29, the suspect cases raised to 49, with 10 of them "highly" suspect.[24] The government purchased 400,000 oseltamivir doses, which will be distributed through the Social Protection ministry to the affected if there are confirmed cases.[244]

[edit] Ecuador

Health officials are carrying out checks on people with flu symptoms entering the country from sea or air.[53] On 29 April, Ecuador closed its borders to Mexican citizens and foreigners of other nationalities arriving from Mexico for a period of 30 days.[245]

[edit] Peru

The Governor of Callao, Alex Kouri, ordered that all passengers from any infected country, mainly Mexico, Canada and USA, must 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.[246]

The first suspicious case has been detected in the morning of April 27, 2009. It was a Peruvian woman who returned from Mexico.[247]

In Peru 5 people were considered suspects with the virus, but as of April 28 have been confirmed to be healthy and not carrying the H1N1 virus. The government has stated that the country is clean, but efforts are being made to examine slaughterhouses and they are screening incoming passengers from problem areas.[248]

On April 29, Peru's Health Minister Oscar Ugarte confirmed one case of swine flu. Having recently visited Mexico, the patient was flying from Panama to Buenos Aires on April 28, but the flight was diverted to Lima due to her illness. The crew only notified of the suspicion of swine flu only after the passenger had checked in the airport. Three more suspected cases were being investigated. Ugarte also announced the suspension of all commercial flights from Mexico to Peru.[20]

[edit] 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.[53]

[edit] Reporting bias

Measuring the spread and characteristics of an emerging disease such as swine flu is very hard because of the difficulty with obtaining accurate and unbiased information. Two major types of bias that must be controlled for in any epidemiological study follow:

* Selection bias: This is a distortion of evidence or data that arises from the way that the data are collected.

Media bias in reporting swine flu cases and deaths may scew incidence maps based on these media reports. Countries with poor health care systems and poor laboratory facilities may take longer to identify suspected cases and analyse those cases. Passive data collection methodologies (waiting for the patient to come to you) are considered inferior to active data collection techniques (performing random stratified sampling) because of various forms of selection bias.

* Information bias: This is a distortion in the estimate of association between risk factor and disease that is due to systematic measurement error or misclassification of subjects on one or more variables, either risk factor or disease status.

If national governments and local health care services do not accurately report their own data on suspected cases and deaths this will produce a bias in any conclusions drawn for such data. China was accused of doing this over SARS (See WHO accuses China of hiding SARS).

At this time there are no properly controlled epidemiological studies into the strain of swine flu emerging in 2009