Tuesday, February 20, 2018

WHO EMRO MERS-CoV Report - Jan 2018


Although daily reporting from the Saudi MOH has faltered badly this month (see Saudi MOH Reports 2 MERS Cases), with reports issued for only 6 of the past 22 days (see list  below) - last month, before reporting fell off a cliff - we saw a quadrupling of cases over what had been reported in December.


The World Health Organization's EMRO (Eastern Mediterranean Office) issues a monthly summary - usually about mid-way through the month - on the previous month's MERS activity in KSA, and the Middle East.
While these monthly reports are chock full of data, and graphs, and can help us peer into the murky MERS situation in KSA, sometimes even their numbers are difficult to reconcile. 
First  we'll look at January's report, and then compared it to December's.

Click to Enlarge

MERS situation update, January 2018

  • At the end of January 2018, a total of 2160 laboratory-confirmed cases of Middle East respiratory syndrome (MERS), including 773 associated deaths (case–fatality rate: 35.8%) were reported globally; the majority of these cases were reported from Saudi Arabia (1786 laboratory-confirmed cases, including 699 related deaths with a case–fatality rate of 39.1%).
  • During the month of January, 25 laboratory-confirmed cases of MERS were reported in Saudi Arabia including 8 associated deaths. A nosocomial outbreak of MERS occurred in a private hospital in Hafr Albatin region, the date of onset of the first case was 23 January 2018; while on 4 February 2018, three asymptomatic healthcare workers were reported through contact tracing.
  • The demographic and epidemiological characteristics of the cases reported in January 2018 do not show any significant di erence compared with cases reported during the same period from 2012 to 2017. Owing to improved infection prevention and control practices in the hospitals, the number of hospital-acquired cases of MERS has dropped significantly in 2015, 2016 and 2017 compared to previous years.
  • The age group of those aged 50–59 years continues to be the group at highest risk for acquiring infection as primary cases. For secondary cases, it is the age group of 30–39 years who are mostly at risk. The number of deaths is higher in the age group of 50–59 years for primary cases and 70–79 years for secondary cases.

While the reported numbers for January are 25 new cases and 8 deaths, when you look at the ending numbers for December (see excerpt below) we find a jump of 33 cases, and 16 deaths.
At the end of December 2017, a total of 2127 laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV), including 757 associated deaths (case–fatality rate: 35.6%) were reported globally; the majority of these cases were reported from Saudi Arabia (1753 laboratory-confirmed cases, including 683 related deaths with a case–fatality rate of 38.9%).
As to what accounts for these discrepancies? 

The most likely cause is that previously unidentified cases (or deaths) may turn up after  delayed or retrospective lab testing, get added to the total, yet are never detailed. We saw this happen in 2014 (see Saudi MOH: Review Finds 19 `Historical’ MERS Cases Prior to June 2014) and it likely still occurs. 
Additionally - asymptomatic cases - who are tested as contacts of known cases, may not be immediately identified and may account for some back filling of data.
While it would be nice to be able say with some degree of accuracy how many MERS cases have occurred in the Middle East - or around the world - the simple fact is that surveillance probably only picks up a fraction of the cases (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016).
Even with the best of outbreak surveillance and reporting, there's always a bit of `fog' to deal with.
The big question, with the recent erratic reporting from the Saudi MOH, is how much visibility we're going to have going forward.

Hong Kong's Post-Holiday Flu Surge

Credit HK CHP


After a month of very high (mostly influenza B) flu numbers, and the forced closure of all of Hong Kong's schools a week early for the Lunar New Year Holiday, we were beginning to see some subtle signs that their flu epidemic might have peaked, with Friday's average Hospital Occupancy rate and A&E Attendance numbers (see graphic below) unexpectedly having dropped sharply over a period of just a few days.


A 93% occupancy rate is a bit surprising because only 4 days earlier, I blogged about Hong Kong's Hospital Occupancy Rates Rising, with the average occupancy rate reaching  117%. 

Given the importance of the Lunar New Year Holiday in Asia, I suspect a lot of patients may have checked out of the hospital late last week in order to spend it with their families, while others - who maybe should have gone to the hospital - may have put that off until after the New Year.

On Saturday the occupancy rate rose to 97%, on Sunday to 104%, and by Monday was back up to 111%. 
Today's numbers show the average occupancy rate to have reached 119%, with Pok Oi Hospital in the New Territories West dealing with a whopping 138% occupancy rate.  That's an impressive average jump of 26% since Friday.


Some of this sudden rise could also be due to a spike in influenza transmission, propelled  by the traditional large family gatherings, travel, and celebrations, that are part and parcel to the Chinese New Year's celebration. 
With an incubation period of 2 - 4 days, the timing is about right.
Today's South China Morning Post carries the following headline, with a the dismal expectation that this winter's flu epidemic could last until late May.

Hospitals see rush of patients amid flu surge and end of Lunar New Year break, resulting in waits of over eight hours
There remains a desperate need for flu vaccines across the city, with the winter flu peak season expected to last until the end of May 
PUBLISHED : Tuesday, 20 February, 2018, 3:05pm

Although Hong Kong and China have been reporting primarily influenza B this winter, both H1N1 and H3N2 are in the mix as well.  Today Hong Kong's CHP reports on a severe pediatric H1N1 case, in a child who arrived from the Mainland last week.

     The Centre for Health Protection (CHP) of the Department of Health is today (February 20) investigating a case of severe paediatric influenza A infection.
     A 7-year-old boy, who lives in the Mainland and has had good past health, travelled to Hong Kong on February 15 and presented with fever, cough and muscle pain since February 18. He developed seizures the next day and was admitted to Queen Mary Hospital. His nasopharyngeal aspirate tested positive for influenza A (H1) virus upon laboratory testing. The clinical diagnosis was influenza A infection complicated with encephalopathy. He is now in a stable condition.
     Initial enquiries revealed that the patient had not received seasonal influenza vaccination for the current season. His home contacts and travel collaterals are asymptomatic so far. Investigations are ongoing.
     Meanwhile, in view of the continuous high level of seasonal influenza activity locally and the end of the Lunar New Year holiday for schools soon, the CHP today issued letters to schools to appeal for heightened vigilance and reinforcement of preventive measures to mitigate the impact of seasonal influenza.

(Continue . . . )

Most Kong Kong schools remain closed for the Lunar New Year's holiday, but are expected to resume classes on Monday, 26 February.

We'll get the next Hong Kong Flu Express on Thursday, which should tell us more about the post-holiday impact of this year's flu season.

Monday, February 19, 2018

Saudi MOH Reports 2 MERS Cases



The Saudi MOH continues to only intermittently update their MERS-CoV surveillance and reporting page, with an update overnight dated the 17th, announcing 1 new MERS cases (74,F) from Rafhaa listed with `indirect camel contact'.
While `Direct camel contact' is fairly self-explanatory, indirect camel exposure has been defined as: Having visited settings where animals were kept but without having direct contact; or exposure to household members who themselves had direct animal exposure.
This definition covers a lot of possibilities, including asymptomatic transmission from a household member.


For reasons that remain unclear, the Saudi MOH has become increasingly sporadic in updating their surveillance page.   Previously, and for the past 5 years or so, the MOH has issued updates daily even when no cases, recoveries, or deaths were announced.

On this 19th day of February, the MOH has only posted 5 daily updates announcing 2 cases for the month, on their  English language portal.


But there's more.

The Arabic language list shows three more additional daily updates during February, with two containing cases not mentioned on the English side; one on the 9th, and another on the 16th

This latest case makes the second report for today.  
Unfortunately, being posted in a .jpg format, machine translation software won't work for these entries.  Both appear to be from in or around Riyadh, the most recent one with recent camel contact and the other without. 
While the Saudi MOH is under not obligation to publish these reports, they have been greatly appreciated, and their loss - like the cancellation of their Weekly MERS Monitor back in 2016 - would be sorely missed.

South Africa: Endangered African Penguins Hit By H5N8


Last May and June, Highly Pathogenic (HPAI) H5N8 made the jump from West and Central Africa into the southern hemisphere, carried there by migratory birds (see map below), and over the next four months sparked scores of outbreaks in wild birds and commercial poultry in South Africa.

H5N8's Arrival In June Of 2017

By late October (and the arrival of spring in the Southern Hemisphere), outbreaks of H5N8 in poultry ended in South Africa, and we've heard very little over the past 90 days.  
Today, however, the South African press has erupted with numerous reports of H5N8 having been discovered in several African Penguin colonies, producing morbidity and mortality among the endangered birds.  
A statement issued by the South African government follows:
Western Cape agriculture confirms further incidences of highly pathogenic H5N8 avian flu

19 Feb 2018
No new commercial poultry infections but Minister urges caution as avian flu detected in other seabird species
The Department of Agriculture has confirmed that further incidences of highly pathogenic H5N8 avian flu have been detected amongst Western Cape sea bird populations. Amongst African penguins, seven cases from six different sites across the provincial coastline have tested positive.
Due to the status of African penguins as endangered, a decision to treat infected birds has been taken. Treatment protocols are similar to those for flu in humans- appropriate nutrition, hydration, vitamins, and the administration of anti-inflammatory drugs or antibiotics for any secondary infections if necessary. Of the seven cases, one has survived.
No new cases of the disease have been reported in the commercial poultry sector since October.
Minister of Economic Opportunities, Alan Winde said “the management authorities of all major seabird colonies around the coastline are monitoring their zones closely. All necessary precautionary protocols to contain the spread of the disease have been implemented and extended surveillance and collaboration across sectors is assisting with further epidemiological evaluations.”
CapeNature CEO Razeena Omar said “CapeNature is working closely with the state vet and has put procedures in place to monitor the virus and restrict the spread by humans between infected and non-infected areas”.
In respect of other wild seabirds, there is no benefit to be gained from trying to control the virus through culling or habitat destruction.
Affected birds show symptoms such as twitching and head tremors and may have difficulty breathing.  Terns and other flying birds can lose their ability to sustain flight.
Avian influenza is a viral respiratory disease of birds that is primarily spread through direct contact between healthy and infected birds, or via indirect contact with contaminated equipment or other materials. The virus is present in the faeces of infected birds and in discharges from their nostrils, mouth and eyes.
The H5N8 strain has not been shown to infect humans.
Minister Winde has urged that sick sea birds be reported to the nearest seabird rehabilitation centre. As a precautionary measure it is advisable that you do not touch these birds if you have pet birds at home or if you are working in the poultry or ostrich industry.
Members of the public are also urged to report abnormal numbers of dead wild birds to a local state veterinarian or the responsible conservation authority. If possible, members of the public should take a photo, and record the location, species and number of dead birds observed.

Below is a list of contact numbers for seabird rehabilitation centres:
Western Cape:
  • Cape Town and surrounds: SANCCOB 021 557 6155
  • Overstrand and surrounds: African Penguin & Seabird Sanctuary 0725987117
  • Mossel Bay and surrounds:  SAPREC 0823643382
  • Plettenberg Bay and surrounds: Tenikwa 0824861515
Eastern Cape:
  • Port Elizabeth and surrounds: SANCCOB 041 583 1830
Media enquires:
Bianca Capazorio
Tel: 021 483 3550
Cell: 072 372 7044
E-mail: bianca.capazorio@westerncape.gov.za
Province: Western Cape
More on: Agriculture
The persistence of H5N8 in wild birds was widely reported in Europe last summer, although by fall the virus had pretty much disappeared, only to be replaced by a newly reassorted H5N6 virus.
It is now late summer in the Southern Hemisphere, and the finding of H5N8 activity at six sites along the shores of the Western Cape has ramifications not only for the endangered birds, but for a potential return of the virus as summer turns into autumn.
And while penguins are are flightless birds, other seabirds in the area are not, and could potentially spread the virus both locally, and globally via migratory flyways (see map below).

Australian DOH Announces Adjuvanted & High-Dose Flu Vaccines For 2018


Australia, whose `down under' flu season generally begins to ramp up in June and peaks in August, saw a particularly nasty H3N2 flu season last year (see Australia's Flu Epidemic Worsens); one that saw hospitals overrun with patients, and which raised alarms over the effectiveness of last year's flu vaccine.
In September, the Australian CMO Issued A Statement On Flu Vaccine Effectiveness citing a lower than usual VE against H3N2 - particularly among the elderly - as a contributing factor to last summer's high flu-related mortality rate.
By October, the the first estimates of Australia's VE were published (see Eurosurveillance: Low H3N2 Vaccine Effectiveness In Australia's 2017 Flu Season), where we learned that while the flu vaccine performed reasonably well against H1N1 (50%) and the Influenza B (57%) - it's VE against seasonal H3N2 averaged only 10%.

Of course, Australia hasn't been alone.  Last summer Hong Kong, Taiwan and Southern China all reported unusually severe H3N2 epidemics where concerns were raised (particularly in Hong Kong) over the effectiveness of their vaccine.
And this winter, interim estimates of the flu vaccine's effectiveness against H3N2 have ranged from 17% (in Canada) to 25% (in the United States).
Although their DOH had already embraced the use of quadrivalent (4 strain) flu vaccines - unlike in North America and parts of Europe -  High Dose and Adjuvanted  vaccines for the elderly were not licensed, and therefore unavailable last year in Australia.

Hoping to avoid a repeat of last year's devastating flu season, the DOH has announced the licensing of both the Fluzone High Dose® and adjuvanted (Fluad®) flu vaccines for those over 65 for the upcoming 2018 flu season.
Ground-breaking flu vaccines to protect millions of Aussies

The Australian Government will provide two new ground-breaking flu vaccines to over three million Australians aged 65 years and over - free of charge.

Page last updated: 19 February 2018

PDF printable version of Ground-breaking flu vaccines to protect millions of Aussies - PDF 357 KB

Joint Media Release
The Hon. Malcolm Turnbull MP
Prime Minister

The Hon. Greg Hunt MP
Minister for Health
Sunday, 18 February 2018

The Turnbull Government will provide two new ground-breaking flu vaccines to over three million Australians aged 65 years and over - free of charge.

This is a direct response to last year’s horrific flu season, which had a devastating impact around the world, and aimed squarely at saving lives.

More than 90 per cent of the 1,100 flu related deaths in 2017 were by people aged over 65 years of age.

The Turnbull Government and the Chief Medical Officer, Professor Brendan Murphy, have worked behind the scenes for many months to bring two new flu vaccines to Australia for the first time.

The vaccines have been fast-tracked to ensure lives are saved and that older Australians receive greater protection.

These new vaccines – Fluad® and Fluzone High Dose® – were registered in Australia to specifically provide increased protection for people aged 65 years and older.

From April 2018, both vaccines will be available through the National Immunisation Program following a recommendation from the Pharmaceutical Benefits Advisory Committee.

These new trivalent (three strain) vaccines work in over 65s by generating a strong immune response and are more effective for this age group in protecting against influenza.

These vaccines have been specifically made for the elderly, as their immune systems respond less effectively to vaccines.

Professor Murphy is continuing to investigate ways to improve protection from seasonal influenza, particularly for the elderly.

This includes mandating a requirement for residential aged care providers to provide a seasonal influenza vaccination program to all staff.

Additionally the Aged Care Quality Agency is continuing a review of the infection control practices of aged care services across the country.

The outcomes will inform new guidelines around the areas of the greatest risk to the safety, health and wellbeing of care recipients.

We must continue to do all we can to protect those Australians who are most at risk.

Under the National Immunisation Program, those eligible for a free flu shot include people aged 65 years and over, pregnant women, most Aboriginal and Torres Strait Islander people, and those who suffer from chronic conditions.

Last year more than 4.5 million doses of the influenza vaccine were provided at no cost to Australians who were most at risk from the flu.

Vaccination saves lives and they are fundamental to our health system.

It can save the life of the person receiving the vaccine, but importantly it also protects those who are unable to vaccinate due to health reasons.

Annual vaccination is the most important measure for preventing influenza and its complications and we encourage all Australians to get vaccinated.

We encourage all Australians aged over six months old to get a flu vaccination this year before the peak season starts in June.

Today we can also announce the following the four strains which will be contained within this year’s Southern Hemisphere vaccines:

  • A(H1N1): an A/Michigan/45/2015(H1N1) pdm09 like virus
  • A(H3N2): an A/Singapore/INFIMH-16-0019/2016(H3N2) like virus
  • B: a B/Phuket/3073/2013 like virus
  • B: a B/Brisbane/60/2008 like virus
The composition of the Australian vaccine is decided by the Australian Influenza Vaccine Committee in consultation with the World Health Organization.
          (Continue . . . )

How much of a difference these two vaccines would  have made in last summer's epidemic is unknown. While more studies are underway, early research suggests they both may help enhance the flu vaccine's effectiveness in those over 65.  The CDC explains:
Does the higher dose vaccine produce a better immune response in adults 65 years and older?

Data from clinical trials comparing Fluzone to Fluzone High-Dose among persons aged 65 years or older indicate that a stronger immune response (i.e., higher antibody levels) occurs after vaccination with Fluzone High-Dose. Whether or not the improved immune response leads to greater protection has been the topic on ongoing research. A study published in the New England Journal of Medicine indicated that the high-dose vaccine was 24.2% more effective in preventing flu in adults 65 years of age and older relative to a standard-dose vaccine. The confidence interval for this result was 9.7% to 36.5%. A separate study published in The Lancet Respiratory Medicine reported that Fluzone High-dose was associated with a lower risk of hospital admissions compared with standard-dose Fluzone for people aged 65 years or older, especially those living in long-term care facilities. The study compared hospitalization rates among more than 38,000 residents of 823 nursing homes in 38 states during the 2013-14 flu season.
Are there increased benefits of FLUAD™ compared to unadjuvanted seasonal flu vaccines for this age group?

Studies that have tested Fluad’s ability to generate an immune response against an influenza virus (immunogenicity) have found that antibody levels were comparable to levels induced by unadjuvanted trivalent seasonal flu vaccines (e.g., Agriflu). However, an observational study conducted in Canada among adults 65 years of age and older during the 2011-2012 flu season found that FLUAD™ was significantly more effective in preventing laboratory-confirmed influenza compared with an unadjuvanted standard-dose inactivated influenza vaccine.

After the disappointing  VE numbers reported in last week's MMWR: Interim Estimates of 2017–18 Seasonal Influenza Vaccine Effectiveness (VE) — US Feb. 2018 - particularly for those over 50 -  there is going to be a lot of interest in just how well these vaccines performed this winter compared to the regular vaccine in the elderly.

Sunday, February 18, 2018

Russia : A Late Season Flu Surge & 3 NAI Resistant H1N1 Viruses



About a month ago, in Russia As An Outlier in This Year's Flu Epidemic, I wrote that even as North America, Europe, and Asia were all reporting heavy outbreaks of influenza, as of Epi Week 2 Russia had yet to cross the epidemic threshold, coming closest (under by 1.4%) in early December (week 51).

A bit out of the ordinary, as we saw reported six weeks ago in Eurosurveillance: Changes In Timing Of Influenza Epidemics - WHO European Region 1996-2016, over the past 2 decades Russia's flu seasons have tended to peak earlier with each passing year. 
Every flu season is different, and nothing is set in stone.
While flu in Russia receded from its initial peak in early December flu activity has begun to rise again over the past couple of weeks, and in the latest (week 6) flu surveillance report from the Russian Institute of Influenza, their rate of influenza has finally crossed the epidemic threshold.

Since our last look at epi week two, H1N1pdm09 has surged (see chart below), while H3N2 has decreased.  Influenza B continues strong, making up about 35% of samples tested.


Some excerpts from the Week 6 Russian Epidemic Situation Report, including reports of 3 H1N1 viruses in Moscow showing signs of resistance to NAI (Neuraminidase Inhibiting) antiviral drugs.   I'll return with a bit more antiviral resistance.

Week 05.02.2018-11.02.2018

Influenza and ARI morbidity data

Epidemiological data show increase of influenza and other ARI activity in Russia in comparison with previous week. The ILI & ARI incidence rate (77.5 per 10 000 of population) was above by 6.8% the new nationalwide baseline (72.6) calculated by RII NIC for 2017-2018 season.

ILI and ARI epidemic thresholds were exceeded in 6 of 61 cities collaborating with two WHO NICs in Russia.  



Influenza and ARI morbidity data.  Increase of influenza and other ARI activity was registered during week 06.2018 in Russia. The ILI & ARI incidence rate (77.5 per 10 000 of population) was above by 6.8% the national wide baseline.

Etiology of ILI & ARI morbidity. The overall percent of respiratory samples positive for influenza  was estimated as 10.0%. Proportion of influenza A(H1N1)pdm09, A(H3N2) and B viruses was estimated as 29.0%, 35.1% and 35.5%, respectively. 

Antigenic characterization. 39 influenza viruses were characterized antigenically in two NICs, including 14 influenza A(H1N1)pdm09 viruses, 7 influenza A(H3N2) strains and 18 influenza type B strains. All influenza A(H1N1)pdm09 and A(H3N2) strains matched influenza vaccine strains for the season 2017-2018. 15 influenza type B strains of Yamagata lineage were like B/Phuket/3073/2013 reference virus, 3 influenza type B strains of Victoria lineage were antigenically related to B/Brisbain/60/2008 virus.

Genetic characterizationFull-genome NGS of 58 influenza positive samples and viruses from 6 cities was conducted. 16 influenza A(H1N1)pdm09  viruses belonged to phylogenetic group 6B.1 with amino acid substitutions in HA S84N, S162N and I216T.
According to phylogenetic analisis of HA 18 of 22 tested influenza A(H3N2) viruses belonged to clade 3C.2a carring aa substitutions L3I, N144S, F159Y, K160T, N225D and Q311H in HA1. Four influenza A(H3N2) viruses belonged to genetic subgroup 3C.2a1 and carried aa substitutions K92R, N121K, T135K and H311Q. 2 influenza B viruses of Victoria-lineage belonged to genetic subgroup 1A (B/Brisbane/60/2008-like). All 18 influenza B viruses of Yamagata-lineage belonged to clade 3 (B/Phuket/3073/2013-like) and had substitution L172Q and M251V in HA1.

Susceptibility to antivirals. Most viruses were susceptible to NA inhibitors excluding three influenza A(H1N1)pdm09 strains isolated in Moscow which had H275Y amino acid substitution in NA responsible for highly reduced susceptibility to oseltamivir and zanamivir.
14 influenza strains tested in MUNANA-assay for antiviral resistance to NA inhibitors in RII NIC, including 3 A(H1N1)pdm09 strains isolated in St.Petersburg, 4 A(H3N2), two B Victoria strains and 5 B Yamagata viruses were susceptible to oseltamivir and zanamivir. All influenza A strains tested were resistant to rimantadine.
Percent of positive ARI cases of non-influenza etiology (PIV, adeno- and RSV) was estimated as 24.7% of investigated patients by IFA and 16.7% by PCR. Last weeks RSV dominated among ARI agents.

In sentinel surveillance system clinical samples from 164 SARI and ILI/ARI patients were investigated by rRT-PCR. 10 (12.5%) influenza cases were detected among SARI patients, including 1 influenza A(H1N1)pdm09 case, 5 influenza A(H3N2) cases and 4 influenza B cases. Among ILI/ARI patients 28 (33.3%) influenza cases were detected, including 4 influenza A(H1N1)pdm09 cases, 14 influenza A(H3N2) cases and 10 influenza B cases.
         (Continue . . . )

During the 2008-2009 flu season (just before the 2009 H1N1 pandemic arrived) public health officials were scrambling because the old H1N1 virus had - in the space of a year - gone from showing about 1% resistance to oseltamivir (aka `Tamiflu') to being nearly 100% resistant. 
The CDC was forced to issue major new guidance for the use of antivirals (see CIDRAP article With H1N1 resistance, CDC changes advice on flu drugs).
This resistance was due to the acquisition of an H275Y mutation - where a single amino acid substitution (histidine (H) to tyrosine (Y)) occured at the neuraminidase position 275 (Note: some scientists use 'N2 numbering' (H274Y)). 

Perhaps the one saving grace of the 2009 pandemic is that it supplanted the old H1N1 virus with a new one that was still susceptible to oseltamivir.  We've been watching ever since then for any signs that the new pH1N1 virus has been gaining resistance, but for the most part, the news has been pretty good.
Rates of resistant pH1N1 viruses have remained low - around 1% - and like we saw prior to 2007, have generally been seen in (often immunocompromised) patients after they were placed on antivirals - due to `spontaneous mutations’.
The most recent FluView report from the CDC reports testing 431 H1N1 viruses since Oct 1st 2017, and finding only 4 (0.9%) showing signs of resistance.   

That said, we have seen a few worrisome instances of H1N1pdm viruses showing resistant to NAI antiviral drugs around the globe, including:
 For all of these reasons, we keep a sharp eye out for any signs of growing antiviral resistance in influenza around the world. Somewhat reassuringly, as the reports above show, previous clusters of NAI resistance in H1N1pdm have failed to take hold.
That said, we don't have enough information to know whether these three resistant viruses reported from Moscow are significant or not.
We don't know if any of these these cases are epidemiologically linked, if they occurred after treatment had begun (aka `spontaneous mutations'), how many viruses have been characterized this year in Moscow, or any other particulars.

Hopefully we'll get some additional information in next week's report.