A Personal Account of the Flu

I recently received this from a friend of mine:

Ten days after returning from Mexico (Cancun – Maya Riviera) I was very, very sick. Sheila was also very sick – but not as severe. The week before we were both very, very tired.

I have relatively good health, don’t get sick too often, and recover fairly quickly. I haven’t been this sick in years; a once in 10 years flu for me.

Last time, about 8-10 years ago just before Christmas, I had a Norwalk type stomach flu; stayed in bed and ran to the washroom for about 3 days.

In 1973, when I was doing a work term at Philips in The Netherlands, I was sent “home” (Graduate Students Residence) for a week.

I also had a bad flu in the 1980s, but I can’t remember the details.

This time I had fever – 38 C for about 6 days – slept for 2 1/2 days – plus all the typical flu symptoms.

As with millions of others, I don’t have a Family Doctor.

So I went to Emergency at the local Hospital, where the Doctor said I had a bad case of the flu with no complications.

On Mon 27 Apr, after the “swine flu” news broke, I decided to drop in at Emergency at the local Hospital.

I reminded them how sick I was after returning from Mexico, but Triage wasn’t interested.

I don’t know if I needed to do anything else - I don’t think it will make any difference at this stage.

We “quarantined” ourselves, did our best not to infect anybody, and Sheila and I recovered well fairly quickly.

What do the experts truly fear about this pandemic ?

1. The number of confirmed cases of H1N1 is very high, and there are innumerable cases that came and went unreported because people just recovered. The percentage of fatalities is very low.

There are definitely some unusual things happening with this current pandemic:
a) the age group of those afflicted is generally lower than seasonal flu;
b) flu in July is not normally an issue in the Northern Hemisphere

2. H1N1 is a relatively mild disease, however it spreads very, very easily.

3. There is still an influenza virus called H5 avian flu. Avian flu infrequently crosses the species barrier to infect humans. And when it does it is not very transmissible from person to person.

4. However, the H5 avian flu virus is much more pathogenic with some reports of at least to 50% of people infected with avian flu actually die from it.

5. There is a fear that the H1N1 virus which is now in Asia will infect birds that have H5 avian influenza. The genetic material of the two viruses will get combined and produce a new influenza strain.

6. So we’ll have a new virus with the pathogenicity of the current H5 avian flu, and the ease of transmission of the novel H1N1 that is currently crossing the world.

Baby Protection for Restaurants and Shopping Carts

Using items in public that other people have inadvertently contaminated is a real source of passing viruses. Children are especially at risk.

I have seen two ideas that are intriguing in this area. One is called a Shopping Cart Cover. The push-bar on shopping carts is supposedly very contaminated. In a typical day, a supermarket cart can be exposed to the drippings from chicken and meat, and even young children still in diapers. Labs found several types of bacteria and fungus that could cause disease, especially in people with fragile immune systems like children. The most serious bacteria found was enteroccocus facaelis – indicating the presence of fecal matter. On other carts bodily fluids like blood, mucus and saliva were found. A cover, like the one in this picture (http://www.babyspree.com/ ), isolates the baby from the shopping cart and can also be used in a restaurant high-chair. In both cases, the baby is protected from the contaminants from previous users. This cover is available from the above website, but is also in most baby stores.

My search for “contaminated shopping carts” on Google found 159,000 hits. A search for “contaminated restaurant high chair” found 10,200 hits. A search for “shopping cart cover” found 1,560,000. These indicate that there are real dangers for infants and lots of places to buy protective covers.

The second idea is a plastic cover which you can stick to the restaurant table in front of your child. This isolates them from whatever is on, or embedded in, the table. The best ones are sticky on the underside so that they don’t move around as your child enjoys their meal. These covers are disposed of at the end of the meal. The one that I found is at http://www.tabletopper.com/tabletopper/Products/?Name=table_topper .

Both ideas are clever ways to help protect your baby from bacteria and viruses that can live for up to 10 hours on shopping carts, restaurant tables and high chairs.

“What can we expect from H1N1 this fall?”

Thanks to trancy.net

From his office at the Mayo Clinic, flu pandemic expert, Dr. Greg Poland is keeping a close eye on the southern hemisphere and how H1N1 virus is spreading. While we’re in the midst of a sunny summer, it’s winter flu season there. Poland says, “We’re talking tens of thousands of cases and close to 1,000 deaths by now.”

He says, “One thing of concern early on in Argentina in part is they were seeing case fatality rates that were somewhere in the 2 to 2 1/2% range. Now in the U.S. our case fatality rate has been under, well under, 1%. About .4 to .5%. But 2 to 3% is the same case fatality rate that historians think happened in 1918.

The 1918 flu pandemic killed more than 600,000 in the U.S. So the question is, could H1N1 become as deadly?

There are concerns.

One is that in the southern hemisphere, H1N1 has completely replaced seasonal flu.

Poland says, “What’s happening down there is mimicking what was seen in 1918 and again in 1968. This pandemic virus is fitter and is outpacing, outcompeting, replacing all the seasonal virus.”

Plus there are a few H1N1 cases that have been resistant to the anti-viral drug Tamiflu.

Of course vaccine is being made for H1N1 but manufacturers say they may only get 30% to 50% of the doses they originally hoped for, putting even more pressure on a tiered rationing system that would give health care workers and children the vaccine first.

H1N1 Spreading Fast than We Can Count !

The World Health Organisation (WHO) said on Thursday that the H1N1 flu pandemic was the fastest-moving pandemic ever and that it was now pointless to count every case.

The United Nations agency, which declared an influenza pandemic on June 11, revised its requirements so that national health authorities need only report clusters of severe cases or deaths caused by the new virus or unusual clinical patterns.

“The 2009 influenza pandemic has spread internationally with unprecedented speed. In past pandemics, influenza viruses have needed more than six months to spread as widely as the new H1N1 virus has spread in less than six weeks,” it said in a statement on the new strain, commonly known as swine flu.

It has become nearly impossible for health authorities and laboratories to keep count of individual cases — which have mostly been mild — as the virus spreads, according to the 193 member-state agency.
from: trancy.net

Actions for Novel H1N1 Influenza Planning and Response for Medical Offices and Outpatient Facilities

from: http://www.cdc.gov/h1n1flu/10steps.htm

It is critical to assure that medical offices and other outpatient facilities (e.g., outpatient/ambulatory clinics, outpatient surgery centers, urgent care centers, physical therapy/rehabilitation offices or clinics) that provide routine, episodic, and/or chronic healthcare services can manage an increased demand for services in the midst of a novel H1N1 influenza outbreak. Ensuring a sustainable community healthcare response will be important for a likely recurrence of novel H1N1 flu in the fall. See CDC’s H1N1 website for up-to-date information.

1. Develop a Business Continuity Plan – Novel H1N1 flu outbreaks will impact your organization, employees, suppliers of critical materiel, and your family. Identify your office/clinic’s essential functions and the individuals who perform them. Make sure you have trained enough people to properly work in these essential functions and allow for potential absenteeism. Develop a plan that will sustain your core business activities for several weeks. Make sure you have alternate plans for critical supplies in case there is disruption in your supply chains. For information about planning see: http://www.ready.gov/business/plan/index.html.

2. Inform employees about your plan for coping with additional surge during pandemic – Provide clear and frequent communication to ensure that your staff are aware and understand the plan. Explain any policies and procedures that will be used to protect staff and your patients, and to manage a surge of patients. Improve the resiliency of your staff by advising that employees have a pandemic family plan or personal plans.

3. Plan to operate your facility if there is significant staff absenteeism – Are you ready for 20 to 40% of your employees not being able to come to work? Cross training your staff is key to resilience here. What else can be done to assure continuity of operations with reduced staff?

4. Protect your workplace by asking sick employees to stay home – Be sure to ask sick staff to stay home. All personnel should self monitor daily for signs and symptoms of febrile respiratory illness. Staff who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor. Be sure to align your sick leave policies so ill staff can stay home. See What to Do If You Get Flu-Like Symptoms for more information.

5. Plan for a surge of patients and increased demands for your services –Consider using your telephone system to deliver messages to incoming callers about when to seek medical care at your facility, when to seek emergency care, and where to go for information about caring for a person with flu at home (see Interim Guidance for H1N1 Flu (Swine Flu): Taking Care of a Sick Person in Your Home). Consider extending your hours of operation to include telephone triage of patients during a community outbreak.

6. Care for patients with novel H1N1 flu in your facility – Make plans to screen patients for signs and symptoms of febrile respiratory illness at entry to the facility. If feasible, use separate waiting and exam rooms for possible novel H1N1 flu patients; plan to offer surgical masks to symptomatic patients who are able to wear them (adult and pediatric sizes should be available), provide facial tissues, receptacles for their disposal, and provide hand hygiene products in waiting areas and examination rooms. For information on caring for patients see: Interim Guidance for Clinicians on Identifying and Caring for Patients with Swine-origin Influenza A (H1N1) Virus Infection.

7. Take steps to protect the health of your workforce during an outbreak of H1N1 – All healthcare personnel who come in close contact with patients who may have novel H1N1 flu should take precautions to include use of respiratory and eye protection for all patient care activities (see: Healthcare Workplaces Classified as Very High or High Exposure Risk for Pandemic Influenza). For information on the use of infection control measures including use of personal protective equipment for staff, see Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare Setting. Plan now to stockpile sufficient PPE for your staff. (see: Proposed Guidance on Workplace Stockpiling of Respirators and Facemasks for Pandemic Influenza).

8. Provide immunization against seasonal flu at no cost to your staff – In the fall there may be several influenza strains circulating at the same time. Although seasonal flu immunization will not provide protection to novel H1N1 influenza, annual influenza vaccination is recommended for health care professionals and will likely protect against seasonal influenza strains. See: Influenza Vaccination of Health-Care Personnel.

9. Make sure you know about the pandemic planning and response activities of the hospitals, outpatient facilities and local public health in your community – Actively seek information from and coordinate with key medical, clinical facilities and public health departments in your community to learn about how they will manage patients during a pandemic. Medical offices, emergency rooms, urgent care centers and hospitals in communities with outbreaks will likely have difficulty managing a large influx of patients; a coordinated community response is important to manage surge and assure optimal patient care. Develop a plan to manage your patients who do not need to seek emergency services.

10. Plan now so you will know where to turn to for reliable, up-to-date information in your local community – Staff in healthcare settings should monitor the CDC H1N1 Flu website and local and State health department websites for the latest information. See these websites for contact information for local health departments and State health departments.

Be prepared for a range of situations. The true impact of novel H1N1 flu outbreaks in the coming months will not be known until it happens. Be prepared for a possibility that your facility will have significant increased demand for services and the possibility that the fall outbreak may have greater impact than the outbreak in the spring, 2009.

Argentina shuts down

thanks to:

http://trancy.net/2009/07/

Millions of Argentines stayed home from work, churches in Bolivia canceled Mass and Ecuador announced its first fatalities from swine flu on Friday, as the virus continues its spread during the South American winter season.

Businesses including banks, exchange houses, courts and even the stock exchange were shuttered for 24 hours across Argentina. Combined with Thursday’s Independence Day holiday, Argentines effectively got a four-day weekend during which many stayed home and avoided contact with strangers.

President Cristina Fernandez decreed a day off for federal public employees, and a number of regional governments also observed the break — including Buenos Aires province, home to nearly two-fifths of the country’s population.

The goal was to “avoid public gatherings,” provincial Health Minister Claudio Zin said, and lessen the person-to-person spread of the virus blamed for 82 deaths so far in the country. At least 2,677 cases of swine flu have been confirmed.

The government has already doubled the winter vacation to a month for schools, sent pregnant women and other vulnerable workers home for 15 days and urged people to avoid crowds whenever possible.

But not everyone agrees on what measures are necessary.

Some cities shut all cinemas, others halted all public events and at least one ordered restaurants to leave a 3-yard (2.5-meter) space between tables. The government has not banned all large gatherings, saying such a drastic measure is not necessary.

Argentina has more confirmed swine flu deaths than any nation on the continent and trails only the U.S. and Mexico worldwide.

The virus has been found across South America, however, and neighboring Chile has reported far more cases of people sickened: more than 9,000 cases.

Ecuador became the latest to confirm fatalities from swine flu within its borders on Friday, with Health Minister Caroline Chang saying the virus was found in a 28-year-old woman and a 30-year-old man, both of whom died this week in the Andean nation’s highlands.

The Bolivian Roman Catholic Church, meanwhile, canceled all non-Sunday Masses.

In the eastern city of Santa Cruz, home to more than two-thirds of the country’s swine flu caseload, the diocese recommended that worshippers avoid church altogether and instead tune in to radio and TV broadcasts of Mass.

Bolivian authorities have suspended a number of public events including concerts by Puerto Rican reggaeton star Daddy Yankee planned for three cities. The government also approved a second extension of students’ winter holiday, until July 20.

Peru said Thursday that winter break for students will start a week early, because of fears that schools could serve as an incubator for the disease.

Starts like regular flu, then lungs stop functioning

Thanks to:
http://trancy.net/2009/07/08/july-8-starts-like-regular-flu-then-lungs-stop-functioning/

source: Anyone who develops serious flu-like symptoms should seek immediate medical attention, because no one can predict when the H1N1 flu virus, or swine flu, will turn life-threatening in otherwise healthy people, infectious disease experts are warning.

Severe cases are occurring, in which the infection starts off like regular seasonal flu, with fever and cough, but then the lungs rapidly become inflamed and stop functioning.

“It looks to most of us like a primary viral pneumonia that deteriorates five or six days into therapy,” says Dr. Allison McGeer, director of infection control at Toronto’s Mount Sinai Hospital. “It’s really severe illness.”

“If you’re young and healthy, you can recover from that severe lung injury. People do. But it takes a very long time,” Dr. McGeer said.

“Sometimes we’re talking about a month, five weeks on a ventilator before you are breathing on your own. Some people can be left with so much residual lung damage, they will have abnormal lungs for their lifetime.”

Scientists are scrambling to understand why otherwise healthy people are becoming seriously ill with swine flu.

But Dr. McGeer said attempting to identify whom this happens to “is the same as trying to pick out people who, faced with Group A [streptococcus], get necrotizing fasciitis — flesh-eating disease — when most of the rest of us get nothing, or minor illness,” she said. “The parallel is, I think, identical.

“If you have underlying illness, if you are pregnant, there are things we know are risk factors,” Dr. McGeer said.

“But I don’t think there’s anything that labels these people any more than there’s something that labels people who get necrotizing fasciitis.”

As of July 3, there had been 8,883 confirmed cases of the H1N1 flu virus across Canada, 663 of which have led to hospitalization, and 29 of which have ended in death.

And as the number of cases climb, H1N1 is showing signs that it can move outside the respiratory tract to other parts of the body, something regular flu viruses normally do not do.

Researchers from the Centers for Disease Control and Prevention in Atlanta found H1N1 virus in the small intestines of ferrets infected with HIN1 isolates taken from three people who developed mild, severe and fatal flu.

The finding could explain why swine flu is causing vomiting and diarrhea in about 40% of cases, symptoms that are not typical of garden-variety flu.

“That’s not normal. Influenza should just be in the lung,” said Earl Brown, an influenza expert at the University of Ottawa. “This is the first time a human flu has done this in a ferret. The question is: How does it get there? You don’t like to see a flu virus move outside the lung.”

The virus did not spread to other organs, such as the kidney or brain. But it suggests H1N1 influenza A is hardier and can survive in the environment longer than normal flu.

High amounts of the virus were also found in lung tissue, “which we don’t typically see with seasonal strains,” said Terrence Tumpey, a microbiologist at the Centers for Disease Control’s influenza division.

They also found significant weight loss in the ferrets infected with the new swine virus.

“It tells us that this virus has the capability of causing more illness in mammals, in comparison to the seasonal strain,” Dr. Tumpey said.

The ferret is considered the best model to study flu in humans. “Generally, the disease you get in the ferret mirrors the disease you get in humans,” Dr. Brown, of the University of Ottawa, said.

Meanwhile, new, non-pandemic influenza has been found in two hog-farm workers in Saskatchewan, and a third case is under investigation.

The affected workers have fully recovered

What is swine flu?

thanks to http://trancy.net/


What is swine flu?
“Swine influenza (also called swine flu, hog flu, and pig flu) is an infection of a host animal by any one of several specific types of microscopic organisms called “swine influenza virus”. In 2009 the media labeled as “swine flu” flu caused by 2009’s new strain of swine-origin A/H1N1 pandemic virus just as it had earlier dubbed as “avian flu” flu caused by the recent Asian-linage HPAI (High Pathogenic Avian Influenza) H5N1 strain that is still endemic in many wild bird species in several countries.

The 2009 swine flu outbreak in humans is due to a new strain of influenza A virus subtype H1N1 that contains genes closely related to swine influenza. The origin of this new strain is unknown. However, the World Organization for Animal Health (OIE) reports that this strain has not been isolated in pigs. This strain can be transmitted from human to human, and causes the normal symptoms of influenza.”

What else?
Swine influenza/pandemic flu does not cause fever in a certain percent of the population. Do not use lack of fever to clear a person of infected status. Rapid tests for influenza may also turn up negative while the person is still infected. Manufacturers of these tests have said that they may or may not detect novel H1N1 and may have up to a 50% false negative rate.

What is this about kids and swine flu?
The median age of people hospitalized (in hospital) due to swine flu is 15. This does not happen during seasonal flu. Seasonal flu pretty much only kills the very young and very old. Swine flu, so far, the majority of deaths have been in teenagers or middle-aged people.

Also, see this excerpt from Quebec (Canada): “The Public Health Agency of Canada says just over five per cent of the people confirmed to have swine flu in this country have been treated in hospital. The agency estimates one-quarter of those hospitalized had an underlying medical condition.”
This means that three-quarters (75%) of people hospitalized did not have an underlying medical condition – that they were normally healthy individuals.

Is swine flu deadlier than normal flu?
See this report (PDF). The case fatality rate (CFR) of the pandemic strain is estimated at 0.4% (0.3%-1.5%). This is much deadlier than seasonal flu – if you scale up the numbers with the percentages, many more will die compared to seasonal flu.

How is swine flu spread?
The same way as regular seasonal flu. However, much more people exposed to swine flu will go on to develop it compared to seasonal flu because there is zero immunity to swine flu present. Most people have some kind of little immunity to seasonal flu.

What are some possible problems in the future?

* H5N1 avian flu: Swine flu has moved into Egypt and other countries that have avian flu. Avian flu kills almost every person it infects. Scientists are worried about these two combining and hitting a middle ground in fatality ratios.
* H1N1 seasonal flu – Southern Hemisphere: Flu season has ended in the Northern Hemisphere. However, it’s starting to be active in the Southern Hemisphere. Seasonal flu worldwide is resistant to Tamiflu, where swine flu is susceptible to Tamiflu. Both of these viruses are H1N1, which means drug resistance could be passed along to swine influenza.

Why is the United States (and other countries) no longer testing for swine flu in healthy people?
This is partly because of two things:

* Lack of resources: The RT-PCR specific test for swine influenza is more time consuming and takes much longer than a rapid test (which can’t tell if it’s swine flu specifically)
* Lack of necessity: The flu season has ended in North America – there is either little or no more seasonal flu. Almost all cases of rapid-test Influenza A are now swine flu. As such, there are more cases than are “confirmed” – possibly hundreds of thousands times more cases.

Scientists Link Influenza A (H1N1) Susceptibility to Common Levels of Arsenic Exposure

Scientists Link Influenza A (H1N1) Susceptibility to Common Levels of Arsenic Exposure

This is from a press release by The Marine Biological Laboratory
http://www.mbl.edu/news/press_releases/2009_pr_05_18.html

MBL, WOODS HOLE, MA—The ability to mount an immune response to influenza A (H1N1) infection is significantly compromised by a low level of arsenic exposure that commonly occurs through drinking contaminated well water, scientists at the Marine Biological Laboratory (MBL) and Dartmouth Medical School have found.

Joshua Hamilton, the MBL's Chief Academic and Scientific Officer and a senior scientist in the MBL's Bay Paul Center; graduate student Courtney Kozul of Dartmouth Medical School, where the work was conducted; and their colleagues report their findings this week in the journal Environmental Health Perspectives.

"When a normal person or mouse is infected with the flu, they immediately develop an immune response," says Hamilton, in which immune cells rush to the lungs and produce chemicals that help fight the infection. However, in mice that had ingested 100 ppb (parts per billion) arsenic in their drinking water for five weeks, the immune response to H1N1 infection was initially feeble, and when a response finally did kick in days later, it was "too robust and too late," Hamilton says. "There was a massive infiltration of immune cells to the lungs and a massive inflammatory response, which led to bleeding and damage in the lung." Morbidity over the course of the infection was significantly higher for the arsenic-exposed animals than the normal animals.

Respiratory infections with influenza A virus are a worldwide health concern and are responsible for 36,000 deaths annually. The recent outbreak of the influenza A H1N1 substrain ("swine flu")--which is the same virus that Hamilton and his colleagues used in their arsenic study--to date has killed 72 people in Mexico and 6 in the United States.

"One thing that did strike us, when we heard about the recent H1N1 outbreak, is Mexico has large areas of very high arsenic in their well water, including the areas where the flu first cropped up. We don't know that the Mexicans who got the flu were drinking high levels of arsenic, but it's an intriguing notion that this may have contributed," Hamilton says.

The U.S. Environmental Protection Agency considers 10 ppb arsenic in drinking water "safe," yet concentrations of 100 ppb and higher are commonly found in well water in regions where arsenic is geologically abundant, including upper New England (Massachusetts, New Hampshire, Maine), Florida, and large parts of the Upper Midwest, the Southwest, and the Rocky Mountains, Hamilton says.

Arsenic does not accumulate in the body over a lifetime, as do other toxic metals such as lead, cadmium, and mercury. "Arsenic goes right through us like table salt," Hamilton says. "We believe for arsenic to have health consequences, it requires exposure day after day, year after year, such as through drinking water."

Arsenic exposure not only disrupts the innate immune system, as the present study shows, it also disrupts the endocrine (hormonal) system in an unusually broad way, which Hamilton’s laboratory discovered and first reported in 1998.

This research was funded by the Dartmouth Toxic Metals Research Program Project by a grant from NIH-NIEHS and its Superfund Basic Research Program (grant P42 ES007373).

H1N1 Statistics from WHO July 6

http://www.who.int/csr/don/2009_07_06/en/index.html

July 6 H1N1
			In last 3 days
Where	Cum Total		New Cases		Increases
	Cases	Deaths	Cases	Deaths	Cases	Deaths
Algeria	5	0	0	0	0%
Antigua/Barbuda	2	0	0	0	0%
Argentina	2485	60	898	34	36%	57%
Australia	5298	10	730	1	14%	10%
Austria	19	0	4	0	21%
Bahamas	7	0	1	0	14%
Bahrain	15	0	0	0	0%
Bangladesh	18	0	6	0	33%
Barbados	12	0	0	0	0%
Belgium	54	0	5	0	9%
Bermuda	1	0	0	0	0%
Bolivia	416	0	133	0	32%
Bosnia/Hezegovina	1	0	0	0	0%
Brazil	737	1	0	0	0%	0%
British Virgin Islands	2	0	0	0	0%
Brunei Darussalam	124	0	39	0	31%
Bulgaria	10	0	0	0	0%
Cambodia	7	0	0	0	0%
Canada	7983	25	0	0	0%	0%
Cap Verde	3	0	0	0	0%
Cayman Islands	14	0	0	0	0%
Chile	7376	14	0	0	0%	0%
China	2040	0	226	0	11%
Colombia	118	2	17	0	14%	0%
Cook Island	1	0	1	0	100%
Costa Rica	277	3	50	1	18%	33%
Cote d'Ivoire	2	0	0	0	0%
Croatia	1	0	1	0	100%
Cuba	85	0	12	0	14%
Cyprus	109	0	39	0	36%
Czech Republic	15	0	0	0	0%
Denmark	66	0	3	0	5%
Dominica	1	0	0	0	0%
Dominican Republic	108	2	0	0	0%	0%
Ecuador	204	0	41	0	20%
Egypt	78	0	11	0	14%
El Salvador	319	0	66	0	21%
Estonia	13	0	0	0	0%
Ethiopia	3	0	0	0	0%
Fiji	2	0	0	0	0%
Finland	47	0	4	0	9%
France	310	0	10	0	3%
. French Polynesia	4	0	2	0	50%
. Guadaloupe	2	0	2	0	100%
. Martinique	3	0	1	0	33%
. New Caledonia	12	0	6	0	50%
. Saint Martin	1	0	1	0	100%
Germany	505	0	35	0	7%
Greece	151	0	42	0	28%
Guatemala	286	2	32	0	11%	0%
Guyana	2	0	2	0	100%
Honduras	123	1	0	0	0%	0%
Hungary	11	0	0	0	0%
Iceland	4	0	0	0	0%
India	129	0	25	0	19%
Indonesia	20	0	12	0	60%
Iran, Islamic Republic	1	0	0	0	0%
Iraq	12	0	1	0	8%
Ireland	74	0	23	0	31%
Israel	681	0	104	0	15%
Italy	146	0	16	0	11%
Jamaica	32	0	0	0	0%
Japan	1790	0	344	0	19%
Jordan	23	0	1	0	4%
Kenya	15	0	3	0	20%
Korea, Republic of	202	0	0	0	0%
Kuwait	35	0	0	0	0%
Laos	5	0	2	0	40%
Latvia	1	0	0	0	0%
Lebanon	49	0	2	0	4%
Libya	1	0	1	0	100%
Lithuania	3	0	0	0	0%
Luxembourg	6	0	2	0	33%
Macedonia	2	0	2	0	100%
Malaysia	112	0	0	0	0%
Malta	24	0	22	0	92%
Mauritius	1	0	0	0	0%
Mexico	10262	119	0	0	0%	0%
Montenegro	10	0	1	0	10%
Morocco	17	0	0	0	0%
Myanmar	1	0	0	0	0%
Nepal	5	0	0	0	0%
Netherlands	135	0	1	0	1%
. Aruba	5	0	0	0	0%
. Curaçao	8	0	0	0	0%
. Sint Maarten	7	0	0	0	0%
New Zealand	1059	3	147	3	14%	100%
Nicaragua	321	0	13	0	4%
Norway	41	0	0	0	0%
Oman	4	0	1	0	25%
Palau	1	0	0	0	0%
Panama	417	0	0	0	0%
Papua New Guinea	1	0	0	0	0%
Paraguay	106	1	3	1	3%	100%
Peru	916	0	378	0	41%
Philippines	1709	1	0	0	0%	0%
Poland	25	0	6	0	24%
Portugal	42	0	15	0	36%
Qatar	23	0	13	0	57%
Romania	41	0	5	0	12%
Russia	3	0	0	0	0%
Saint Lucia	1	0	0	0	0%
Samoa	1	0	0	0	0%
Saudi Arabia	114	0	25	0	22%
Serbia	15	0	0	0	0%
Singapore	1055	0	177	0	17%
Slovakia	18	0	0	0	0%
Slovenia	14	0	9	0	64%
South Africa	18	0	6	0	33%
Spain	776	1	16	0	2%	0%
Sri Lanka	19	0	2	0	11%
Suriname	11	0	0	0	0%
Sweden	84	0	10	0	12%
Switzerland	76	0	4	0	5%
Syria	1	0	1	0	100%
Thailand	2076	7	662	4	32%	57%
Trinidad/Tobago	65	0	12	0	18%
Tunisia	5	0	2	0	40%
Turkey	40	0	0	0	0%
Uganda	1	0	0	0	0%
Ukraine	1	0	0	0	0%
United Arab Emirates	8	0	0	0	0%
United Kingdom	7447	3	0	0	0%	0%
. Guernsey	5	0	0	0	0%
. Isle of Man	1	0	0	0	0%
. Jersey	11	0	0	0	0%
USA	33902	170	0	0	0%	0%
. Puerto Rico	18	0	18	0	100%
. Virgin Islands	1	0	1	0	100%
Uruguay	195	4	0	3	0%	75%
Vanuatu	2	0	0	0	0%
Venezuela	206	0	2	0	1%
Viet Nam	181	0	50	0	28%
West Bank/Gaza Strip	60	0	30	0	50%
Yemen	8	0	1	0	13%
Grand Total	94512	429	4591	47	5%	11%