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I don't want to end the week on an alarming note, and - let's face it - there's been enough alarmist reporting about H1N1 swine flu.

But I would like to draw your attention to a couple of issues which many of you are likely to pick up elsewhere on the web or perhaps in the papers.

The first is a big jump in the global death toll. The World Health Organization said the number of deaths was up around 1,000 on a week ago, reaching at least 7,826 worldwide since the H1N1 virus emerged in April. That should neither surprise nor alarm you. We are now getting into the peak flu season. Seasonal flu kills several hundred thousand very elderly and frail people each year. The difference with swine flu is that the majority of deaths are in the under-65s.

On a more positive note, the WHO said that the epidemic may have peaked in parts of the northern hemisphere. That seems to be the case in the UK and in the United States, which has had several weeks of falling levels of flu.

Secondly, I have picked up via that two patients in France, in different hospitals, have died from mutated H1N1 swine flu. (For those who don't know, the ³ÉÈË¿ìÊÖ monitoring service is based in Caversham in Reading; it listens to news broadcasts from around the world and provides accurate translations.)

The monitoring translation of La Chaine Info Television went like this:

French newsreader: "The health authorities dreaded this. The H1N1 virus is in the process of mutating. The phenomenon reported in Norway has also been detected in France in two deceased patients who were not related in any way and who were in hospitals in two different cities. This mutation could increase the virus's ability to affect certain airways, as well as the lungs."

Read like that, it seems pretty scary, and it is certainly not good news that mutations are occurring. But, as has been pointed out by me and by many of the wise men and women who post comments here, mutations are what we should expect with flu. Flu is an RNA virus in which genetic replication is pretty poor and which makes lots of mistakes. It's the reason that flu viruses drift and the reason we need a new flu jab every winter.

The mutations reported in France have been seen in Norway and in several other countries, and .

The French mutation has been found in two cities, but we need to know a lot more about it before becoming unduly alarmed. The patients may have been immuno-compromised, making them more susceptible to mutated viruses, and we don't have any evidence that mutated strains are spreading in the wider community.

To sum up, mutation and deaths are sadly unavoidable when it comes to H1N1 swine flu. But this pandemic is still reassuringly mild for the vast vast majority of those infected.

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Around one million people in England are now estimated to have been vaccinated against swine flu.

Across the UK, 10 million doses of the vaccine have been distributed to GPs and hospitals.

That one million figure refers to those in the , such as those with chronic asthma, heart and other organ disease, immune problems and pregnant women.

Clearly there is still a long way to go. There are nine million people in the priority groups in England, and around 11.5 million across the UK. Then add to that the three million or more under fives who will be offered the jab after that.

Professor David Salisbury, Director of Immunisation at the Department of Health said he :

"All GPs have now had some vaccine and we are now at the stage of re-stocking them and so the brakes can come off to some extent. We'd like to get the priority groups vaccinated before Christmas, and there will be enough vaccine to do that. GPs don't want to call in patients if they are unsure there have enough vaccine, but now they know they have it in the fridge they can go full throttle."

Professor Salisbury said he wanted doctors to get through the priority groups as quickly as possible so that they could move on to immunising children under five.

Carers for the elderly and disabled will also be entitled to receive the swine flu jab once the initial priority groups have been cleared.

I hope this answers some of the questions many of you have raised about the roll-out of the vaccine.

There are no figures yet for the uptake of vaccine among more than two million front-line health workers.

But Ian Dalton, National Director for Flu Resilience said that "informal conversations" had shown promising levels of uptake. He gave some examples:

• West Midlands Ambulance Service has offered the jab to around 1,000 front line staff and 70% have accepted.
• Guy's and St Thomas' Hospitals have received 2,000 doses and used 1,500 already.
• They have also immunised 4,000 staff against seasonal flu, double the number last year.

So how much swine flu is there in Britain at present? Estimated figures from across the UK suggest cases are falling very slightly but the number of deaths is rising sharply.

Indeed the past week has seen the biggest single rise in deaths since the pandemic began.

UK deaths to date related to H1N1 swine flu: 245
163 England
13 Northern Ireland
46 Scotland
23 Wales

Why are deaths rising if cases are falling? Firstly, remember that weekly estimates for the number of cases of swine flu are probably wildly out (but are useful for showing trends over time).

The latest weekly estimate for England was 46,000 cases of swine flu with a cumulative total of 760,000. But since the Health Protection Agency now reckons that one in five children may have had swine flu, that cumulative figure maybe just a tenth of the real total (and that's just my guess).

I've discussed this apparent contradiction about falling cases and rising death rates earlier this month - something that has been seen in other countries.

It's important to note that there is no evidence that the H1N1 swine flu virus is mutating into something more deadly.

Finally a few graphs - very useful for showing trends. My thanks to the Department of Health and the RCGP for supplying the data:

You can see that the rate of flu is now about average for this time of year but well below the peak we saw in July.

This is a snapshot of the number of patients in hospital in England with suspected swine flu related illness as of 25 November. It's always worth showing this because it's a reminder that while flu is mild for most, for a small minority it can be very serious.

This is the first time I've seen this. It reveals the death toll from swine flu, in England from week to week. You can see that the rate has risen throughout November.

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It's been one of the big questions of this pandemic. Just how many of us in Britain have actually had swine flu?

Knowing that would be incredibly useful, as the bigger the proportion infected, the further we are into this pandemic and the less likely there will be a further sting in its tail.

The and parents connected to early school outbreaks.

With one school in south west England they tested around 500 people. They found that although around one in 10 children fell ill, three to five times as many got infected and developed antibodies.

After analysing this and other data relating to the number of children being seen by GPs, the HPA has now come up with these interesting estimates:

• Up to one third of children in swine flu hotspots (such as England and the West Midlands) have already been infected with the H1N1 virus.
• Across the UK up to one in five children has had had swine flu.
• About half of those who get infected show no symptoms.

This is all very reassuring. Professor Maria Zambon from the HPA said:

"We didn't get the pandemic that we planned for and you might say that we've been lobbed a soft ball. There hasn't been high case mortality, the virus is sensitive to drugs, and we've been able to make vaccine and roll it out. I am incredibly grateful that we are not dealing with a pandemic of H5 (bird flu)."

Professor Zambon said the virus had had a relatively low impact on older adults and that was probably explained by pre-existing immunity. The HPA has these estimates:

• For those aged over 50 up to four in 10 people have pre-existing protective antibodies to the H1N1 pandemic virus.
• If you are under 50 it falls to around one in 10 of the population.

The professor, who is an acknowledged world expert on flu, did utter a few words of caution. "Influenza is full of mystery and intrigue. It has lots of twists and turns" and she predicted that mutations of the swine flu virus should be expected. She also pointed out that there could still be a substantial outbreak of seasonal flu over winter.

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Canada, like the UK is one of many countries worldwide using the Pandemrix swine flu vaccine.

Now Canadian health officials and the manufacturers GlaxoSmithKline have asked doctors to stop using a single batch of 172,000 doses.

It comes after - which might include breathing problems, raised heart rate and skin rashes.

GSK is investigating the reports - this may result in the withdrawal of the batch. It's reported that one in 20,000 people suffered reactions to this batch - five times the expected number.

None suffered long term ill effects. The vaccination programme in Canada is continuing, using other supplies of Pandemrix.

A spokeswoman for GSK Gwenan White said that 7.5 million doses of Pandemrix had been distributed in Canada and the action taken over the batch was a purely precautionary measure. "It may well be that after further investigation, the batch can be used" she said.

Canada's doses are produced at a manufacturing plant in Quebec. None of the stocks of vaccine bound for the UK are affected - all produced at a plant in Dresden, Germany.

Only yesterday GSK announced that more than 40 million doses of Pandemrix had been distributed globally - .

GSK also announced results from a clinical trial among children which showed a strong immune response from one dose of Pandemrix.

Update, 08:58, Wednesday 25 November: I've received this statement from Geoffrey Matthews at the Public Health Agency of Canada about Arepanrix which is the Canadian name for Pandemrix:

"The Public Health Agency of Canada, is reviewing reports of a higher than normal number of adverse events associated with one particular lot of the H1N1 flu vaccine that was distributed over the week of November 2, 2009.

"As a precautionary step, on November 18 Health Canada asked GSK to instruct provinces who have received adjuvanted GSK vaccine Arepanrix doses from Lot 7A ( BC, AB, SK, NB, ON, PEI) not to use any remaining doses of that lot for vaccination.

"This will allow Health Canada, GSK, the Public Health Agency of Canada and the relevant jurisdictions to investigate the cause of the higher than expected number of allergic reactions to the vaccine in persons immunized with that Lot.

"Placing vaccine lots on hold is not an unusual occurrence. Over the past few years, Health Canada has placed specific lots of other vaccine on hold pending further investigation.

"A total of six adverse events (all analyphlaxis) associated with this lot have been reported (the lot in question comprises 172,000 doses). All six individuals who experienced severe allergic reactions have fully recovered.

"Anaphylaxis is a severe allergic reaction that is readily treatable, but can be life-threatening. Therefore it is considered a serious adverse event.

"The Public Health Agency of Canada, Health Canada (the regulator) and the provinces and territories have been working together, and with Canada's vaccine manufacturer, to ensure that all adverse events are reported and assessed.

"People who have received the vaccine and have not had an allergic reaction, have no reason to be concerned.

"The H1N1 flu virus vaccine has proven to be both safe and highly effective. The fact that we have identified a potential safety issue underscores that our monitoring system works."

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Health officials in Wales say a strain of Tamiflu-resistant H1N1 swine flu has passed from person to person in a Cardiff hospital. The first news of this story was broken on this blog just a couple of hours ago. The National Public Health Service for Wales says that five patients at the University Hospital of Wales in Cardiff were all diagnosed with swine flu resistant to Tamiflu. All have severe underlying health conditions. Three appear to have acquired the infection in hospital.

We know that sporadic resistance to Tamiflu has developed in individuals being treated for swine flu. But this appears to be the first definite case in the world of person-to-person transmission of a Tamiflu-resistant strain. in September had a number of other possible explanations.

In truth it's not easy to be absolutely certain that there has been person-to-person transmission in Wales. Chris Lines, director of communications for Public Health Wales, said "we can't find any other explanation for this, so our confirmation of person-to-person spread is based on the lack of evidence of any other means of transmission."

He gave some more detail about the patients: "Of the five, two have recovered and been discharged having recovered. Of the three in hospital, one is in critical care and two are on the wards but being isolated from other patients."

So how important is this? Hopefully this will be a viral dead-end and it won't go any further. I'm told all the patients were immunocompromised and so especially vulnerable to developing Tamiflu resistance.

Dr Roland Salmon, director of the NPHS Communicable Disease Surveillance Centre, said:

"The emergence of influenza A viruses that are resistant to Tamiflu is not unexpected in patients with serious underlying conditions and suppressed immune systems, who still test positive for the virus despite treatment."

Finally, just to stress, there's no evidence or suggestion that a "new" Tamiflu-resistant strain of H1N1 virus is now "out there" in the community. But public health officials in Wales will be very busy this weekend tracing contacts to ensure they have contained this among this small group of patients.

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I am indebted to a loyal follower of this blog for tipping me off about a breaking news story in Wales.

Health officials in Cardiff are investigating the spread of a Tamiflu-resistant strain of swine flu at University Hospital Wales. The strain has infected a small number of patients, all of whom have serious underlying health conditions.

Roche, the maker of Tamiflu, tells me that there have been 57 cases worldwide of people developing resistance to Tamiflu while taking the drug (seven of these in the UK).

But what happened at University Hospital Wales may be quite different. Here, someone developed resistance - and then, I understand, this strain appears to have been passed from person to person in the hospital.

There's been only one other similar case in the United States between two people at a summer camp, but the resistant strain did not spread any further. .

Health officials in Wales tell me that more tests are being carried out to confirm exactly what happened, and they are not yet confirming person-to-person spread.

All the patients are said to be recovering and being cared for in controlled environments, so there is no risk to anyone else.

Tamiflu is an antiviral and can reduce the risk of the complications of flu, as well as shortening the duration of the illness. The UK has enough doses for half the population. Any spread of a Tamiflu-resistant strain of swine flu would be a serious public health concern - but there is no evidence to suggest that this has happened.

Obviously this is a developing story, and I'll bring you more when I get it.

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A few words on the decision to against H1N1 swine flu to young children.

It will be offered to all children aged between six months and five years of age. That's around three million children in the UK.

They'll have two jabs, three weeks apart. One dose of vaccine appears to give good immunity, and it's possible that the European regulators may amend their recommendation to one jab at some point.

The Department of Health has released details of a Mori poll - 73% of parents asked said they'd give the vaccine to their children. We filmed at a playgroup in Birmingham - the city with the highest rate of swine flu in England - and most parents were very positive.

Obviously all parents will have to make personal decisions about whether to have their children immunised - the clear recommendation from vaccine experts, paediatricians and public health officials is that the vaccine is safe, with few apparent side-effects, and that it's the best (and the only way) to protect children.

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I am frustrated, I admit. I would like to know what the uptake of the H1N1 swine flu vaccine is. But I don't. I have a hunch and a feeling and a bit of anecdotal evidence, but that's not really good enough, is it?

Plenty of commenters here have said they are going to have or had had the jab. Plenty have expressed concerns, among them quite a few pregnant women. But what percentage of the 11 million people in at-risk groups are going to have the jab?

Professor Steve Field of the Royal College of GPs said it was far too early to work out uptake figures. He pointed out that some GP surgeries had got their first doses only last week. Clearly you can't have a jab (or turn it down) until you are offered it.

Which brings us to surveys, polls and rune reading (okay, not the last).

A "snapshot survey" of 107 GPs in England for Pulse, a magazine for health professionals, indicated that only of patients offered the jab, only 46% accepted.

This was widely reported, but it worries me that this is a self-selecting group. And 107 GPs out of 37,213 in England is not a representative sample.

An GfK-NOP telephone poll for the ³ÉÈË¿ìÊÖ of just over 2,000 people in the UK asked the following questions about swine flu.

If you were offered the swine flu vaccine would you be happy to have it?
• Yes 52%
• No 27%
• Don't know 21%
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If you said "No" or "Don't know" to the above question, which of the following factors would influence your decision?
• Don't think it's needed 36%
• Don't think it will work 11%
• I'm concerned about safety 43%
• Don't know what the vaccine would do 35%
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NHS staff are being offered the vaccine to protect themselves and also to help protect patients they are looking after who may be more vulnerable to flu. Do you think they should agree to have it?
• Yes 70%
• No 10%
• Don't know 20%

Some interesting answers there, but remember: this was a sample of the UK population, not a sample of people in the at-risk groups.

You would think that if 2,000 people with asthma, diabetes and immune disorders were polled, the percentage willing to have the vaccine would be higher. So it tells us a bit, but not that much.

So finally I resorted to a single GP practice. Dr Dean Marshall is a GP in Edinburgh, but he is also chairman of the BMA Scottish GPs committee. How is immunisation against swine flu going at his practice?

"It's very early days, but so far we've not been getting a fantastic response from pregnant women. Because they are at greatly increased risk of complications from swine flu, we have been ringing them up to offer the vaccine and about half have said yes, but the rest declined or are still thinking about it.
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Overall, we've immunised about 300 people in the at-risk groups. You always get some reluctance with any new vaccine and we've not had long to get a public education campaign going with swine flu. We are clearly going to have to work hard to convince many people to have the jab."

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I've already written a lot about the H1N1 swine flu vaccine on this blog. But with one in six Britons currently eligible for the jab, you'll forgive me for returning to the topic again and again.

Many people have questions about the vaccine and wonder whether they should have it. On that there is very clear advice from all medical bodies and public health experts: if you are in an at-risk group (such as those with asthma, heart disease, lung problems, immune disorders or are pregnant), you really should have the vaccine.

But what of the manufacturers of Britain's preferred swine flu vaccine? I thought it would be a good idea to put some questions to GSK, which researched, developed and produces Pandemrix.

Dr Thomas Breuer is based at GSK's massive vaccine plant at Rixensart in Belgium. His full title is Senior Vice President Global Clinical R&D and Chief Medical Officer - which means he is the person to quiz about the vaccine.

So here are ten questions about the swine flu vaccine.

Read the rest of this entry

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I've had a lot of questions from pregnant women and their partners about the swine flu vaccine.

So it is timely that the Department of Health is issuing a new leaflet for pregnant women. It should be available in GP surgeries from next week, .

We don't yet know what the uptake of the vaccine has been among pregnant women.

The Chief Medical Officer for England, Sir Liam Donaldson, recognises that many women will be agonising over what to do:

"It's obvious that pregnant women worry about catching flu and having a vaccine... it is a difficult time for them and a difficult decision. It is their choice, but the information we have given out will help people to take that decision. The best way for them to protect themselves and their baby is to have the vaccine."

Vaccine distribution

Have you had your swine flu jab yet? The Department of Health says that 6.6 million doses of Pandemrix have been distributed so far and that, by the end of this week, "virtually all GPs" will have received their first delivery of vaccine. Officials say the campaign is "on track".

Healthy children next?

I have said several times that an announcement extending immunisation to all children is inevitable.

The Department of Health continues to insist that no decision has been made and it won't confirm that healthy children will be the next group. A decision is expected within two weeks.

But rather like the plot of a thriller where you guess the ending long before you get to it, it is abundantly clear that children will be the next in line for the jab, once at-risk groups have been immunised.

There is no rush to make an announcement, as there are millions of people with asthma, heart disease and other conditions to immunise before children can be targeted.

Cases down but deaths up

Meanwhile, the H1N1 virus continues its unpredictable course. The number of cases is falling in much of the UK, but there has been a significant increase in the number of deaths.

There were an estimated 64,000 new cases of swine flu in England in the past week, a fall of 20,000.

There were decreases in Northern Ireland and cases seem to have stalled in Wales (on one measure in Wales cases rose, and on another they fell).

Only Scotland showed an definite increase. Health officials think the dip in cases may be due to the recent half-term school holidays.

At the same time, there has been a big jump in the number of deaths, up by 28 to 182 across the UK.

But there is no evidence that the virus is becoming more virulent. Sir Liam Donaldson said:

"[T]he lab scientists continue to watch the virus and it's not changing, but it looks like now the virus is out of the summer it has a more serious spectrum about it."

You can see that the red line is showing a bit of a dip. This is good news, as it gives GPs a breathing space to get people immunised.

It's reckoned that 620,000 people in England have now had swine flu - but that is a very rough estimate and the true total may be much higher.

The vast majority have had a mild illness, but of concern is the small minority who need hospital treatment.

This demonstrates the ugly side of swine flu. As of 0800 on Wednesday, there were 785 people in hospital in England with swine-flu-related illness, 173 of those in intensive care. There were 109 people in hospital in Scotland.

The overall number of deaths linked to swine flu now stands at 154 for the UK: 105 in England; 31 in Scotland; eight in Wales and 10 in Northern Ireland.

That represents a rise of 28 deaths from the previous week. The average age of those who have died is 44.

I've included this data because it illustrates the difference between pandemic and seasonal flu. You can see that, whereas those over the age of 60 make up the peak group hospitalised by seasonal flu, it is children who are most affected by swine flu.

This graph shows that whereas 94% of deaths from seasonal flu are in the 65+ age group, with swine flu the fatalities are much more evenly spread.

Indeed, 60% of the deaths so far have been of people under the age of 45. 20% of those who have died had no underlying health conditions.

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Influenza viruses have been causing sickness for thousands of years so it may seem curious that there is still a huge amount that we don't understand about them.

This applies especially to H1N1 swine flu which, admittedly, has only been circulating in humans for a matter of months.

A series of research projects in the UK have been announced which will examine every aspect of the swine flu virus - in pig and human populations, and in hospital intensive care units.

£7.5 million pounds of funding has been given by the Medical Research Council (MRC), Wellcome Trust, and Biotechnology and Biological Sciences Research Council (BBSRC) along with some government support.

The research will aim to answer many of the questions which commenters on this blog have raised, and more besides:

• Why do some people and not others become seriously ill with swine flu?
• What proportion of people who are infected have no symptoms (what's known as asymptomatic)?
• If you are asymptomatic, can you still spread flu?
• How useful are antivirals?
• How effective is the vaccine?
• How does H1N1 swine flu behave in pigs?
• Is there a risk that the virus could evolve into a more virulent form in pigs?
• Is there a need for a vaccine for pigs to slow the spread of the virus?

Fluwatch

, which will follow up to 10,000 people and look at the duration and severity of symptoms, their access to treatment, use of antivirals and uptake of the vaccine.

We should not have to wait long for results. Dr Hayward said he hoped to release initial data before Christmas.

This study should help scientists work out what proportion of the population has had swine flu. This is crucial because at present we have only tenuous estimates from the Health Protection Agency which are subject to a huge margin of error.

Last week's estimated cumulative number of cases was 620,000 in England (with a range from 289,000 to 1,278,000).

The reason we don't have a clear idea of how many people are infected is because the majority of those who get flu, never go anywhere near the health service and only the sickest patients get tested for the virus.

If we knew what proportion had no symptoms or recovered without bothering their doctor, it would help us understand how quickly we may get through this pandemic.

It will also look at how effective antivirals have been in treating flu - a hot topic for months. Some have criticised the policy here of offering Tamiflu to anyone who says they have flu-like symptoms.

Dr Fred Hayden from the Wellcome Trust (Professor of Medicine at the University of Virginia) pointed to a study in the New England Journal of Medicine last month. This looked at nearly 300 patients admitted to hospital in the United States.

Dr Hayden said:

"[F]or those admitted to hospital, the average time they waited before getting antivirals was three days, for those admitted to intensive care it was six days and for those who died it was eight days."

He said that early treatment, even in uncomplicated seasonal flu, could reduce the risk of complications.

The Mechanisms of Severe Acute Influenza Consortium (MOSAIC)

Thankfully the principal investigator, Professor Peter Openshaw from Imperial College London, came up with the .

A team of scientists from England and Scotland will look at up to 500 people hospitalised with flu during the pandemic and try to find out what factors contributed to the severity of their disease.

For example, was there something about their genetic make-up which made them more susceptible to the virus, or was it due to variations in the virus itself?

They'll be taking around 40 samples from each volunteer and doing extensive virology and bacterial work in several UK labs.

This study will take about a year to complete and, like the others, could yield useful information for future pandemics.

Combating Swine Influenza (COSI) Initiative

There are two studies here looking at the evolution and spread of pandemic H1N1 virus in pigs and how to develop ways to slow the spread of the virus in animals and humans.

The research will be led by Professor James Wood at the University of Cambridge and Professor Ian Brown at the Veterinary Laboratories agency at Weybridge.

Professor Wood said that for the last 10 years scientists had concentrated more on avian influenza and there was a lack of detailed surveillance in pigs.

"It's important we understand the evolution of the H1N1 pandemic" he said. "We need to look at where it came from and how it's evolving. It's possible that it may take a different evolutionary course in pigs and pose a different threat to humans."

He pointed out that farmers had passed the H1N1 pandemic virus to pigs in Argentina, Australia, the USA and Canada.

One issue that has been puzzling me is why the pandemic virus is currently so stable. We are always told that RNA viruses like flu have a high mutation rate. It's why people need a flu jab each autumn.

Professor Wendy Barclay, virologist at Imperial College London said there was genuine uncertainty about the H1N1 swine flu virus: "We don't know why it's so stable" she said.

Nonetheless, she had a theory:

"It currently has a huge number of hosts (people) to infect and so has no pressure to mutate. But as more people develop immunity it will have to work a lot harder and so we will expect to see drift (mutations) which might be accompanied by changes in its virulence."

That might of course mean that swine flu has a sting in its tail. "Pandemic, what pandemic?" has been the refrain from some journalistic colleagues recently. And it's true that the first pandemic of the 21st Century is a viral pushover for the vast majority of us.

But for a small minority it is a serious threat, hospitalising hundreds of Britons each week, a good proportion of whom have no underlying health problems.

The sooner we know why flu is able to breech the defences of some people and not others, the sooner we might be able to develop better ways to beat the virus.

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A few words about how the H1N1 virus is progressing on its relentless attempt to reach every corner of the globe.

show the virus has now spread to more than 199 countries and territories and that there have been more than 6,000 deaths.

Although every death is a tragedy, that is a remarkably small number given that seasonal flu is reckoned to contribute to the deaths of at least 250,000 people per year. It is yet further evidence of the generally mild nature of the virus.

Having said that, swine flu has a sting in its tail.

Australia, like several other southern hemisphere countries, has recently emerged from its winter flu season.

Deaths were low compared to seasonal flu, but hospital intensive care units had not seen anything like it in 40 years; indeed, since the pandemic of 1968-70.

It sums up the apparent contradiction about this pandemic: mild for most, but very serious for a small minority.

Those at greatest risk of complications are pregnant women and anyone with an existing health condition such as asthma. That's why these groups are being immunised first.

Unlike seasonal flu, which tends to kill the frail elderly, the average age of those who've died from the virus here in the UK is 44. One in five of those who have died had no previous health problems.

As I have said before, swine flu should not be a reason to panic - nor is it something to dismiss out of hand. We can all do our bit to minimise the spread of the virus by .

Several of you have asked about which, in just a few weeks, has recorded more than 250,000 cases of flu-like illness, with 235 people needing intensive care and 70 deaths.

As far as I can make out, there does not seem to be anything unusual about the outbreak there. One health official said it was probably a reflection of the poor state of the health service that the virus had had such an intense effect.

Crucially, samples of the virus have shown that it is not mutating, so is the same H1N1 pandemic strain that is circulating worldwide. As long as that remains the case, we should feel reassured.

Finally, if the virus has spread to 199 countries and territories, does anyone know where on the planet has not experienced swine flu?

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It is curious that although the overall number of H1N1 swine flu cases has been fairly static over the past week, intensive care units continue to come under increasing pressure. The Chief Medical Officer for England, Sir Liam Donaldson, gave his weekly update to journalists via video link from Washington, where he's attending health meetings.

Sir Liam said: "there has been a snowballing of cases in intensive care units in recent weeks which is giving us real concern". He stressed that there was no evidence that the H1N1 virus was mutating. "It is unexplained," he said, adding that he'd met the chief medical officer for New Zealand in recent days who had pointed out that his country had seen a similar phenomenon over their winter. Half-way through their recent flu season there had been a fall in the severity of most cases in the community but an increase in severity in a minority of cases with complications.

My thanks to the Department of Health, as always, for providing this data for the blog. Never before has a pandemic been so closely monitored, in real time. This chart shows that as of 0800 on 4 November there were 848 people of all ages in hospital in England with suspected swine flu. Of these, 172 were in critical care. Last week there were 751 in hospital of whom 157 were in intensive care.

That seems surprising when you look at what's happening to swine flu from weekly consultations with GPs.



This is a key graph for understanding what the H1N1 virus is doing. As always, look at the solid red line. You'll see that it actually dipped a bit in the week up to 1 November. Health officials think this is probably the result of children being on half-term, rather than the start of a downward trend.

The Health Protection Agency estimates there was a slight increase in cases of swine flu in England this week, to 84,000 cases, up from 78,000 the week before. Remember though there is a huge margin for error because very few people are tested for the virus and we still don't know the proportion of those who get infected yet have such a mild illness that they either don't know they've had swine flu, or they cope without bothering the health service.



This is a useful chart because it shows, by age group, the ratio of people in the community who have been hospitalised. Children under five represent the biggest group needing hospital treatment. If you look at the five to 15 age range, this is the only group where there was a fall in the ratio hospitalised over the past week (probably due to half-term).

Vaccine

I promised to update you on how the distribution of swine flu is going. Health officials confirmed that 6.4 million doses of the GSK vaccine Pandemrix were now in the UK and of these, 4.4 million had been distributed. Sir Liam said that by the end of next week virtually all GPs would have received their first delivery of swine flu vaccine. The warehousing and distribution of the vaccine is being handled by , which on its website says that it delivers 40% of all domestic pharmaceutical products in the UK.

Movianto also has 1.43 million doses of Celvapan, the swine flu vaccine made by Baxter. This is being reserved for the tiny proportion of people who have a severe egg allergy as (unlike Pandemrix) it is not grown in eggs. The potential downside of Celvapan is that two doses are required to confer immunity compared to one dose of Pandemrix, which explains why the GSK vaccine is the one primarily recommended by the Department of Health.

A reminder that , initially, to people considered most at risk of complications of flu (such as those with asthma, heart disease or immune disorders).

In addition, front-line health workers are being immunised. There are no figures yet on uptake of the jab among NHS staff, but Ian Dalton, the NHS flu resilience director, said that anecdotal evidence was looking good: "It's very positive," he said. "There's a sense that staff recognise it will protect them, their families and patients."

Extending vaccination

As I've said before, it's just a question of time before the swine flu immunisation programme is extended beyond at-risk groups, with healthy children being the next priority.

The Conservative health spokesman Andrew Lansley has formally called on the government to extend vaccination to all school children and college students. Mr Lansley says he's been pressing for this "behind the scenes" for weeks. Sir Liam says it's not a question of whether but when the programme is extended, but they are looking at the best way of doing it. He said an announcement would be made "within a couple of weeks".

Swine flu across the UK

My apologies to those who live outside England. This summary must appear rather England-centric. It's an inescapable fact that I can't get to the swine flu briefings outside London, but I do my best to reflect what's happening UK-wide. It would be great if the four health departments could get together and publish UK data as well as that representing their individual statistics.

To summarise, there have been slight falls in the number of suspected swine flu cases in Scotland and Wales, with a big decrease in Northern Ireland.

In Scotland 17,487 people are thought to have contracted swine flu over the last week, compared with 19,200 cases reported in the previous week.

In Northern Ireland, 215 laboratory-confirmed new cases have been reported in the last week, compared with 142 in the previous week - the department there does not seem to publish an estimated total of those infected, making comparisons difficult. Nonetheless, it does report GP consultations for flu and flu-like illness, which have decreased from the very high level of 280 per 100,000 to 222 in week 44 (21% decrease). Contrast that with the rate of 37.7 in England.

In Wales, 1,971 people contacted their GP in the last week with flu-like symptoms, compared with 2,626 the week before.

Justin McCracken, chief executive of the Health Protection Agency told journalists that in England, around 50% of patients who were being swabbed for suspected swine flu actually tested positive for the H1N1 virus. In Scotland and Wales, the rate is around 40%, while in Northern Ireland it is 80%.

Deaths

The overall number of deaths linked to swine flu now stands at 154 for the United Kingdom - 105 in England, 31 in Scotland, eight in Wales and 10 in Northern Ireland. The average age of those who've died is 44. Four out of five of those who've died have had some underlying health problem.

Useful resources:
Detailed UK weekly epidemiology update

Swine flu figures for Northern Ireland

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Up to now this blog has been exclusively about the threat posed to humans from H1N1 swine flu. But since we are reputedly a nation of animal lovers, I thought some would be interested in what the risks might be to pets. If you don't care about cats, look away now...

that a cat in Iowa has tested positive for H1N1 swine flu, the first time a cat has been diagnosed with this pandemic strain of influenza.

The 13-year-old cat, which has recovered, is thought to have caught the virus from someone in the household who was sick with flu. The AVMA report doesn't say whether the pet's owners have recovered, but hopefully they, like the moggy, are better.

"We've known certainly it's possible this could happen," said Centers for Disease Control and Prevention spokesman Tom Skinner. "This may be the first instance where we have documentation that transmission occurred involving cats or dogs."

The vet who treated the cat, Dr Brett Sponseller, said two of the three people in the cat's home had flu-like symptoms before it became ill. Apparently the cat was lethargic, had lost its appetite and appeared to have trouble breathing.

Dr Ann Garvey, Iowa's state health veterinarian, said it is not yet known how sick cats or other pets could get from swine flu. "Because we haven't seen that many cases, it's difficult to give a blanket assessment on how sick it can make an animal," she said.

So do pets potentially pose a flu risk to their owners? Not according to the AVMA. Officials stressed that there is no evidence that swine flu can be passed from pets to people. "But it's so early in the game we don't know how it's going to behave. But that doesn't appear to be the concern. There's no sense of them passing it on to people," said Michael San Filippo, spokesman for the American Veterinary Medical Association.

Dogs can get influenza but in a form () which cannot be passed to humans.

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