Epidemiological Bulletin Number 85 Week 45 (week ending 14 November 2010)

Foreword

This bulletin provides a weekly overview of the outbreaks and other important public health events occurring in . It includes disaggregated data to inform and improve the continuing public health response by the various partners. It also provides guidance to agencies on issues relating to data collection, analysis and interpretation, and suggests operational strategies on the basis of epidemiological patterns so far. The bulletin is published weekly. Note that the epidemiological week runs from Monday to Sunday. This edition covers week 45 (week ending 14 November 2010).

The C4 team welcomes feedback. Data provided by individual agencies is welcome but will be verified with MOHCW structures before publication.

Acknowledgements

We are very grateful to MoHCW District Medical Officers, District and Provincial Surveillance Officers, Provincial Medical Directors, Directors of City Health departments, Environmental Heath Officers, and MoHCW's National Health Information Unit, who have helped to gather and share the bulk of the information presented here.

Likewise, we acknowledge agencies, including members of the Health and WASH clusters, who have kindly shared their data with our team. MoHCW recognizes and thanks the efforts made by NGOs and other partners assisting in the response and providing support to MoHCW

Highlights of the week ending November 2010:  No new cholera cases reported  203 suspect measles cases reported  Further Decline in Influenza A H1N1(2009)cases reported

Figures

The case definitions can be found in appendix 1 and detailed data by district are shown in appendix 2. See also summary tables (annex 1), maps (annex 2) and graphs (annex 3).

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1

Cholera

18 out of the 62 districts in the country have been affected by the cholera outbreak that started on 4 February, 2010 compared to 54 districts last year at the same time. 790 cumulative cholera cases consisting of 688 suspect cases, 102 laboratory confirmed cases and 21 deaths were reported by the 24th October 2010 to the World Health Organization (WHO) through the Ministry of Health and Child Welfare's (MoHCW) National Health Information Unit. The crude case fatality rate since the outbreak started stands at 2.7% which is 1.6% lower than that of last year. By week 45 2009, 98 522 cumulative cases and 4 282 deaths had been reported since August 2008, with the crude case fatality rate of 4.3%.

Week 45 (8 -14 November 2010)

No new cholera cases were reported. The last cholera cases were reported in week 42. Hence the cholera outbreaks that started in week five are now over because there have been no reports for three weeks.

Geographical distribution of cases

The cases reported so far came from the following districts: , , , , Chivi, Chimanimani, , Chiredzi, , Hurungwe, Kadoma, , Makonde, Mt. Darwin, , Mwenezi, Plumtree and UMP.

Urban/Rural distribution of cases

72% of the cases currently reported are from rural areas. In comparison, during the corresponding week in 2009, 67 % of the cases were from rural areas.

Assessments & response

Surveillance continued in all districts. Case management training for epidemic diarrhoeal disease is being conducted.

Measles

National Overview (September 2009 to 14 November 2010)

12 918 suspected cases and 631 deaths of measles were reported in all the . 691 confimed Measles IgM cases were reported in 61 districts. Bulilima is the only district that has not reported at least one confirmed measles case. However this could probably be due to figures of this new district being lumped together into the . 53 districts have reported confirmed measles outbreaks. The attack rate of suspected cases is 106 cases per 100 000 population.

IgM Positive Cases by Age Group

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2 109 (16%) of the positive IgM cases were below 9 months, 52 (8%) in the 9 – 12 months age group, 129 (19%) were in the 1-5 years age group, 266 (39 %) were in the 5 -14 years age group and 131 (19%) in the above 14 years age group and 4 cases(0.6%) had no agegroup. Hence 529 (77%) of the positive cases were above the routine immunisation age (9 -12 months). See table 3 for detailed distribution of the IgM positive cases by agegroup and and attack rates by district.

Vaccination Status

6821 (53%) of the cases were not vaccinated, 4519 (35%) had unknown vaccination status and 1578 (12%) were vaccinated.

Comparison of Measles Situation for the periods before and after the measles national immunisation days

September 2009 to 4 July 2010 (before NIDs)

10 946 suspected cases were reported of which 602 were confirmed cases. 53 districts reported confirmed measles outbreaks. The attack rate of suspected cases was 90.1 per 100 000 .The attack rate of confirmed cases was 5 per 100 000.

517 deaths were reported from 21 districts.

5 July to 14 November 2010 (after NIDs)

1 972 suspected cases were reported of which 79 were confirmed cases and 114 deaths were reported. 12 districts reported confirmed measles outbreaks namely Bikita, Binga, Chipinge , , , , Lupane, Makonde, Mazowe, Seke and . 10 confirmed measles cases were reported in the last 30 days from: Buhera 4, Chegutu 14, Chikomba 8,Hwedza 10, Gokwe South 7, Gweru 8, Goromonzi 1,Harare 69,Kadoma 4, Kwekwe 9, Kariba 4, 5, Mutasa 15, Mutare 16, Mvuma 5, Mt Darwin 10, Seke 8, Shamva 2,UMP 2, Tsholotsho 2, and Zvimba 1 case. Hence there was one confirmed outbreak in the last 30 days in Gokwe South. The attack rate is 14.5 per 100 000 for suspected cases and is 0.6 per 100 000.

Week 45 (8 -14 November 2010)

203 suspected cases and no deaths were reported this week through the Weekly Disease Surveillance System (WDSS). The suspected cases were from the following areas: Beitbridge 3, Gokwe North 23, Gokwe South 11, Gweru 3, Chegutu 12,Chivi Harare 64, 12, 3, Kadoma 6, Kariba 29, Kwekwe 7, Lupane 2, Makonde 21, Mt. Darwin 4, Mwenezi 66, Shamva 2 and Zaka 1.

8 confirmed measles IgM cases were reported in the last 30 days( 15 October-14 November 2010) from: Beitbridge 1, Chiredzi 1, Chivi 1, Gokwe South 2, Harare 1, Mbire 1, Zvimba 1 . There is no district that reported at least 3 confirmed measles , hence there was no ongoing confirmed outbreak in the country during week 45 .

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3

Comparison of weekly measles indicators for the periods September 2009 to 4 July and 5 July -14 November 2010

Some notable changes in key measles weekly indicators are as follows: 1. Suspected weekly cases declined from 248 to 103. 2. Confirmed weekly cases declined from 14 to 5 cases 3. Weekly deaths also dropped from 12 to 6

Assessments & response

Integrated EPI disese surveillance and case finding continued. Districts are encouraged to continue to search for suspected measles cases and meet the minimum detection rate of 2 suspected cases per 100 000 population per year. Hence at least 5 suspected cases per week are expected to be reported if the cases are uniformly distributed.

The continual reporting of high numbers suspected of suspected measles cases and low numbers (4%) of confirmed measles IgM cases is attributed to strengthening of the measles surveillance system and cases of rubella (German Measles) being misdiagnosed as measles. From next week we will include comparison of confirmed measles IgM cases and confirmed rubella cases.

Influenza A H1N1 (2009)

A suspected outbreak of Influenza A H1N1( 2009) was declared in Tsholotsho on the 15th of October, after having noted increases in cases that presented with severe flu like symptoms. The outbreak was targeting mostly the children (especially school going age) and the under five.Thereafter outbreaks of confirmed Influenza A were reported in Bulilima on 22 October, in Mangwe on 26 October, in Masvingo and Harare on 27 October.First suspected cases of H1N1 reported in Lupane on 28 October. In addition suspected Influenza outbreak was also declared in Beitbridge.

21 600 suspected cases have been reported up to date.

Week 45 (8 -14 November 2010)

3 071 suspect cases cases were reported by end of the week in retrospect from Binga and Lupane. No cases were reported of the current week.

Geographical distribution of cases

H1N1 cases have been reported from 9 Districts namely Binga, Beitbridge, Bulilima, , Harare, Lupane, Mangwe, Masvingo and Tsholotsho.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4

Assessments & response

Surveillance and case management continues in all affected districts.

Assessments were done in Lupane and Binga after they had reported suspected H1N1 cases on the 28th and suspected cases on the 19th October in Binga. The Binga cases were reported on the 29th to the province. The findings of the assesments are as follows:

Characterization of the Epidemic by Place, Person and Time

Characterisation Lupane Binga

Occurrence of First Cases 28th October 19th October

Notification to next level 29th October 29th October

Areas Affected Menyezwa School, Gwayi Simatelele, Resettlement Area, Daluka Sinasengwe,Zumanana Communal Area, Jibajiba ward, Kanyandavhu RHC, Jotsholo RHC and Fatima RHC.

Most Affected Agegroup 5 -14 Years Uniformly Distributed across all age groups

Response Matrix

Response Lupane Binga

Case Management Case definitions and treatment PPE and protocol distributed medical sundries provided

Social Mobilization Community Health Education and CBHWs and distribution of IEC materials community leaders mobilised

Surveillance Contact tracing Encouraged to analyse

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 5 Response Lupane Binga

Active surveillance Epidemiological data Line listing of cases CBHWs and Daily reporting of cases and community deaths leaders involved in active surveillance

Coordination RRT meetings held on weekly Encouraged to basis strengthen EPR plan Partners asked to assist in active surveillance

Challenges Matrix

Challenge Lupane Binga

Case Management RDTs and viral transport RDTs and viral transport media media

Limited availability of Paracetamol and Tamiflu

Surveillance Most health workers not trained in IDSR Fuel Transport and communication

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 6 Annex 1: Summary Tables

Table 1: Cumulative Cholera cases and deaths reported by district as of week 45 2010

District Suspe Confirme Suspecte Confirme Discarde Total Death Attack cted d Cases d Cases d Cases d Cases Case s Rate/1000 Cases Reported s 00 report this ed week this week Beitbridge 0 0 16 1 0 17 0 15.1

Bindura 0 0 0 2 0 2 0 1.3 Buhera 0 0 101 5 0 106 0 44.5 Chegutu 0 0 19 13 32 2 13.1 Chimanimani 0 0 52 10 0 62 51.2

Chipinge 4 0 18 7 0 25 2 8.1 Chiredzi 0 0 45 9 0 54 2 21.3 Chivi 0 0 11 2 0 13 0 7.7 Harare Urban 0 0 1 3 0 4 0 0.3

Hurungwe 0 0 165 6 171 5 55.2 Kadoma 0 0 136 24 0 160 5 62.5 Makonde 0 0 3 1 0 4 0 1.4 Mangwe 0 0 0 1 0 1 0 1.0 Masvingo 0 0 9 1 10 1 3.5 Mt. Darwin 0 0 7 4 0 11 1 5.1

Mutare 7 2 101 8 0 109 2 25.6 Mwenezi 0 0 0 5 0 5 0 3.7 Uzumba 0 0 4 0 0 4 1 3.5 Maramba Pfungwe Total 11 2 688 102 0 790 21 16.5

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 7

Table 2: Age and Sex breakdown of cumulative cholera linelisted cases as at week 45

District Under 5 5-14 15-29 30 Years and

Years Years Years over

Male Female Male Female Male Female Male Female Buhera 0 0 0 1 18 3 8 1 Chiredzi 2 2 5 3 6 9 6 8 Chivi 0 0 0 1 0 1 2 4 Harare 00 0 0 0 0 0 2 0 Chimanimani 4 2 2 7 6 20 10 9 Chipinge 0 2 1 2 0 3 3 4 Masvingo 0 0 0 0 0 1 2 3 Mwenezi 0 0 0 0 0 1 2 1 Beitbridge 0 0 0 0 0 0 0 0 Kadoma 0 9 0 17 0 0 0 0 Mutare 2 2 1 2 45 14 24 15 Total 6 12 9 30 59 42 42 37

Table 3: Distribution of Measles IgM Positive by Agegroup and District of residence since September 2009 – 14 November 2010

District Missing < 9 9 -12 1-5 5-14 >14 TOTAL New Attack months months years years years Cases Rate per 100 000 BEITBRIDGE 0 0 0 2 2 3 7 1 6.2

BIKITA 0 1 0 4 6 0 11 0 6.5 BINDURA 0 0 2 3 0 1 6 0 3.2

BINGA 0 0 1 1 3 4 9 0 6.9 BUBI 0 1 0 2 7 3 13 0 25.3 BUHERA 0 0 1 3 2 0 6 0 2.5 1 6 6 2 5 2 22 0 3.0

CENTENARY 0 0 0 0 2 1 3 0 2.9

CHEGUTU 0 2 0 4 7 0 13 0 11.1

CHIKOMBA 0 1 1 2 3 1 8 0 3.3

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 8 District Missing < 9 9 -12 1-5 5-14 >14 TOTAL New Attack months months years years years Cases Rate per 100 000 CHIMANIMANI 0 0 0 1 1 2 4 0 3.1

CHIPINGE 0 0 1 1 6 4 12 0 9.6

CHIREDZI 0 4 2 1 2 1 10 1 3.3 CHIRUMANZU 0 0 0 1 5 1 7 0 2.8

CHITUNGWIZA 0 11 0 0 5 6 22 0 28.8

CHIVI 1 1 1 2 2 0 7 1 2.0 GOKWE 0 0 0 0 2 0 2 0 1.2 NORTH GOKWE 0 1 1 6 13 6 27 1 11.6 SOUTH GOROMONZI 0 1 2 1 6 0 10 0 3.1

GURUVE 0 1 0 0 1 0 2 0 1.2 GUTU 0 0 0 2 5 1 8 1 4.0 GWANDA 0 0 1 0 0 2 3 0 1.4

GWERU 0 3 0 1 3 3 10 0 7.1 HARARE 2 35 17 16 44 43 156 1 63.6 HURUNGWE 0 2 1 2 4 0 9 0 0.6

HWANGE 0 3 0 1 0 6 10 0 3.2

HWEDZA 0 0 0 3 5 0 8 0 7.3 INSIZA 0 1 0 1 7 0 9 0 11.8 KADOMA 0 1 0 1 5 0 7 0 7.5

KARIBA 0 0 0 0 5 3 8 0 3.2 KWEKWE 0 2 0 3 6 1 12 0 18.8

LUPANE 0 2 1 2 3 3 11 0 4.1 MAKONDE 0 1 1 3 5 2 12 0 11.2

MAKONI 0 1 0 6 3 2 12 0 9.5

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 9 District Missing < 9 9 -12 1-5 5-14 >14 TOTAL New Attack months months years years years Cases Rate per 100 000 MANGWE 0 0 2 0 2 2 6 0 2.2

MARONDERA 0 3 0 2 6 1 12 0 14.2

MASVINGO 0 2 2 1 2 1 8 3 7.2

MATOBO 0 0 0 0 3 1 4 0 1.9 MAZOWE 0 2 1 0 3 3 9 0 8.3

MBERENGWA 0 0 0 0 1 0 1 0 0.5

MBIRE 0 0 0 0 1 0 1 0 1.3 MT DARWIN 0 0 0 1 5 0 6 0 3.0

MUDZI 0 0 0 2 7 0 9 0 4.2 MUREHWA 0 0 1 0 4 1 6 0 4.4

MUTARE 0 1 0 2 4 1 8 0 4.6 MUTASA 0 0 0 3 4 0 7 0 1.7 0 0 0 3 2 1 6 0 3.3

MWENEZI 0 2 1 2 1 0 6 1 3.4

NKAYI 0 0 0 2 1 1 4 0 2.9 NYANGA 0 2 0 3 1 2 8 0 6.6 RUSHINGA 0 0 0 1 2 0 3 0 2.4

SEKE 0 7 0 6 7 3 23 0 31.6 SHAMVA 0 0 0 0 1 0 1 0 1.2 0 0 0 2 1 1 4 0 3.8

TSHOLOTSHO 0 1 0 1 1 0 3 0 3.1

UMGUZA 0 1 0 2 2 1 6 0 4.6

UMZINGWANE 0 1 1 0 1 0 3 0 2.7

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 10 District Missing < 9 9 -12 1-5 5-14 >14 TOTAL New Attack months months years years years Cases Rate per 100 000 UMP 0 0 1 3 3 4 11 0 9.7

ZAKA 0 3 1 3 1 1 9 0 13.5 ZVIMBA 0 1 3 6 8 3 21 1 10.5 ZVISHAVANE 0 1 0 8 17 3 29 0 12.1

TOTAL 4 108 52 128 266 131 689 11 5.7

Table 4: Distribution of Community and Institutional Measles Deaths attributed to Measles as of 14 November 2010

District Community Institutional Total Deaths Deaths Deaths Bikita 11 0 11 Bindura 10 0 10 Buhera 92 4 96 Chegutu 2 0 2 Chimanimani 3 0 3 Chipinge 3 0 3 Gokwe North 18 1 19 Gokwe South 6 0 6 Goromonzi 46 0 46 Guruve 1 0 1 Hwange 2 0 2 Insiza 4 0 4 Kadoma 1 0 1 Makoni 24 5 29 Marondera 20 0 20 Mudzi 31 0 31 Mazowe 72 0 72 Mbire 32 0 32 Murehwa 50 0 50 Mutare 47 0 47 Mutoko 46 0 46 Mutasa 10 0 10 Nyanga 9 0 9 Seke 17 2 19 UMP 55 0 55 Insiza 7 0 7 Total 619 12 631

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 11

Table 5: Comparison of some Measles Indicators before vaccination plus four weeks and after

Indicator September to 5 July –14 4 July ( 44 November weeks) (19 weeks)

Suspected Cases 10 946 1 972

Confirmed Cases 602 89

Deaths 517 114

Cumulative number of Districts that reported 53 12 laboratory confirmed outbreaks

Ongoing outbreaks 0 1

Overall Attack Rate of suspected cases 90 per 100 000 12 per 100 000 Confirmed cases

Table 6: Vaccination Status of Measles Cases by District September 2009 to 14 November 2010

District Not Unknown Vaccinated TOTAL Vaccinated Beitbridge 42 2 16 60 Bikita 32 14 3 49 Bindura 13 0 10 23 Binga 12 1 9 22 Bubi 31 0 4 35 Buhera 586 0 1 587 Bulawayo 64 0 39 103 Bulilima 6 20 1 27 Centenary 7 0 1 8 Chegutu 24 6 6 36 Chikomba 46 7 13 66 Chimanimani 15 0 5 20 1 0 1 2 Chipinge 38 0 14 52 Chiredzi 17 4 0 21

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 12 District Not Unknown Vaccinated TOTAL Vaccinated Chirumanzu 11 41 5 57 417 9 51 477 Chivi 16 3 4 23 Gokwe North 287 66 27 380 Gokwe South 116 4 3 123 Goromonzi 105 6 18 129 Guruve 9 2 2 13 Gutu 14 1 0 15 Gwanda 9 20 8 37 Gweru 40 28 9 77 Harare 2151 1298 779 4228 Hurungwe 22 3 22 47 Hwange 41 42 62 145 Hwedza 20 2 3 25 Insiza 17 2 54 73 Kadoma 80 39 12 131 Kariba 11 40 1 52 Kwekwe 59 32 31 122 Lupane 50 5 5 60 Makonde 73 24 25 122 Makoni 232 16 6 254 Mangwe 7 0 3 10 Marondera 91 10 12 113 Masvingo 64 8 6 78 Matobo 10 22 5 37 Mazowe 51 35 7 93 Mberengwa 4 24 0 28 Mt Darwin 54 13 4 71 Mudzi 150 0 32 182 Murehwa 22 1 5 28 Mutare 215 6 2 223 Mutasa 59 5 7 71 Mutoko 26 3 9 38 Mwenezi 11 4 2 17 Nkayi 25 5 4 34 Nyanga 49 4 7 60 Rushinga 7 2 1 10 3 0 0 3 Seke 1360 28 224 1612

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 13 District Not Unknown Vaccinated TOTAL Vaccinated Shamva 5 0 0 5 Shurugwi 16 7 8 31 Tsholotsho 18 3 10 31 Umguza 17 2 4 23 UMP 14 4 5 23 4 1 1 6 Zaka 23 7 1 31 Zvimba 53 9 12 74 Zvishavane 64 3 4 71 Missing 0 2011 0 2011 TOTAL 7136 3954 1625 12715

Table 7: H1N1 Influenza Cases and deaths as of 7 November 2010

Influenza cases

Province District Suspected Deaths Probable cases Confirmed cases cases (RDT (RT PCR +ve) +ve)/Number tested

Matabeleland Tsholotsho 16823 0 14 12 North

Matabeleland Beitbridge 613 0 - - South Binga 819 0 - -

Bulilima 559 0 6 -

Mangwe 611 0 2 -

Gwanda 480 0 - -

Lupane 1501 - -

Masvingo Masvingo 188 0 8 -

Harare Kuwadzana 6 0 3 1

National total 9districts 21600 0 33 13

(4 provinces)

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 14 Annex 2: Maps

Map 1: Comparison of cumulative cholera cases by district as of week 45 for the years 2009 and 2010

2010 2009

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 15 Map 2: Comparison of Cumulative Measles IgM positive cases and Suspected Measles

case by district reported this year, as at 14 November 2010

Confirmed Cases Suspected Measles Cases

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 16

Map 3:Distribution Suspect and Confirmed Influenza H1N1(2009) Cases as at 14 November 2010

Suspected H1N1 cases Confirmed H1N1 Cases

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 17

Annex 3: Graphs

Graph 1:Ranking of District Cumulative Cholera Cases Reported as at week 45, 2010

Graph 2: Cumulative Cholera Cases by week for the years 2009 and 2010

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 18 Graph 3: Cholera Epidemic Curve Week 5 - Week 45, 2010

Graph 4:Ranking of Confirmed Measles Igm Cases by District Reported from September 2009 to 14 November 2010

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 19 Graph 5:Ranking of Suspected Measles Cases by District Reported from September 2009 to 14 November 2010

Graph 6: Measles Epicurve as at week 45, 2010

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 20 Source: Ministry of Health and Child Welfare Rapid Disease Notification System 21 Graph 7 Comparison of Suspected Measles Cases, Confirmed Measles Cases and Rubella cases September to November 2010.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 22

Appendix 1: Case Definitions

Cholera The Zimbabwe cholera state definition states that "In an area where there is a cholera epidemic, a patient aged 2 years or more develops acute watery diarrhoea, with or without vomiting". ‘’A confirmed cholera case is when Vibrio cholerae is isolated from any patient with diarrhoea”. This is adapted from the WHO case definition for cholera. The inclusion of all ages in the case definition somewhat reduces specificity, that is, inclusion of more non-cholera childhood diarrhoea cases. It, however, does not impede meaningful interpretation of trends. Teams should monitor any shift in the age distribution of cases, which might indicate a changing proportion of non-cholera cases among patients seen.

Suspected measles:

Any person with fever and maculopapular rash and cough OR Coryza (running nose) OR conjunctivitis (Red eyes) OR clinician suspects measles.

Measles Outbreak Definition:

A suspected outbreak is where you have a cluster of at least 5 suspected measles cases in a facility or district within a month whilst a confirmed outbreak is where you have a cluster of at least 3 confirmed measles IgM positive cases.

Lab confirmed: Suspected case of measles with positive serum IgM antibody, with no history of measles vaccination in the past 4 weeks.

Confirmed by epidemiologic linkage: Suspected case of measles not investigated serologically but has possibility of contact with a laboratory-confirmed case whose rash onset was within the preceding 30 days (same / adjacent districts with plausible transmission)

Influenza A H1N1 Influenza A and B are two of the three types of influenza viruses associated with annual outbreaks and epidemics of influenza. Only influenza A virus can cause pandemics. The Zimbabwe IDSR technical guidelines define influenza case by a new sub type (including Avian flu Influenza A H5N1 and Swine flu Influenza A H1N1) as; ‘’Any person presenting with unexplained acute lower respiratory illness with fever (>38 ºC ) and cough, shortness of breath or difficulty breathing in the 7 days prior to symptom onset.’’

Probable case definition: Any person meeting the criteria for a suspected case AND positive laboratory confirmation of an influenza A infection but insufficient laboratory evidence for H1N1 infection.

Confirmed H1N1 case: A person meeting the criteria for a suspected or probable case AND a positive result conducted in a national, regional or international influenza laboratory whose H1N1 test results are accepted by WHO as confirmatory.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 23 There may be difficulty in telling apart mild cases of pandemic influenza from the seasonal influenza.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 24