vaccine is a safe and effective preventive health action with potential benefit in all age groups, existing recommendations that already cover 85% of the population, the lack of awareness of many higher risk persons of their risk factor and the occurrence of complications in some adults without previously recognized risk factors. There was also concern that pH1N1 will continue to circulate in the 2010-2011 season and that a substantial proportion of young adults do not yet have immunity to this virus, which produced higher risk of complications in this age group than is typical for seasonal influenza.

Before making expanded recommendations that may influence Canadian immunization programs nationally, NACI is committed to careful systematic review of the required and available evidence and interpretation in the context of goals and objectives previously established in Canada by a consensus process.^(77)^ As with other new vaccines, this process will be followed in considering population-based indications for expansion of influenza immunization programs. A summary of that analysis in relation to pediatric or other program expansion will be made available when concluded. Until then, NACI continues to encourage influenza vaccine for all Canadians.

Low rates of utilization of influenza vaccine may be due to failure of the health care system to offer the vaccine and refusal by persons who fear adverse reactions or mistakenly believe that the vaccine is either ineffective or unnecessary. HCWs and their employers have a duty to actively promote, implement and comply with influenza immunization recommendations in order to decrease the risk of infection and complications among the vulnerable populations for which they care. Educational efforts aimed at HCWs and the public should address common doubts about disease risk for HCWs, their families and patients, vaccine effectiveness and adverse reactions.

The advice of a health care provider is a very important factor affecting whether a person accepts immunization. Most people at high risk are already under medical care and should be vaccinated during regular fall visits. Strategies to improve coverage include, but are not limited to, the following:

* Standing-order policies in institutions allowing nurses to administer vaccine and simultaneous immunization of staff and patients in nursing homes and chronic care facilities. In these settings, increased vaccination rates are associated with:

* a single, non-physician staff person organizing the program;

* having program aspects covered by written policies; and

* instituting a policy of obtaining consent on admission that is durable for future years.

* Vaccinating people at high risk who are being discharged from hospital or visiting the emergency department.

mesure de prévention sûre et efficace pouvant comporter des avantages pour tous les groupes d'âge, les recommandations existantes qui visent déjà 85 % de la population, le fait que de nombreuses personnes à risque élevé ne connaissent pas leur facteur de risque et la survenue de complications chez certains adultes dont les facteurs de risque n'avaient pas été reconnus précédemment. On craint également que le virus pH1N1 continue de circuler durant la saison 2010-2011 et qu'une proportion substantielle des jeunes adultes ne possèdent pas encore d'immunité contre ce virus qui est associé à un risque plus élevé de complications dans ce groupe d'âge que ce qu'on observe normalement dans le cas de la grippe saisonnière.

Avant de formuler des recommandations qui pourraient modifier les programmes d'immunisation à l'échelle nationale, le CCNI souhaite procéder à un examen systématique soigneux des données requises et des données disponibles et les interpréter à la lumière des buts et des objectifs déjà établis au Canada par voie de consensus^(77)$. Comme c'est le cas pour d'autres nouveaux vaccins, ce processus consensuel sera suivi pour déterminer s'il y a lieu d'étendre les programmes de vaccination antigrippale à d'autres groupes dans la population. Le résumé final de cette analyse concernant l'extension des programmes de vaccination des enfants ou d'autres groupes sera rendu public dès que possible. D'ici là, le CCNI continue d'encourager la vaccination antigrippale chez tous les Canadiens.

Peut-être que les faibles taux d'utilisation tiennent au fait que le système de santé n'offre pas le vaccin et que les sujets qui devraient être vaccinés refusent de l'être parce qu'ils craignent les effets secondaires de cette mesure ou ils croient à tort que le vaccin est inefficace ou inutile. Les TS et leurs employeurs ont le devoir de promouvoir activement, de mettre en œuvre et de respecter les recommandations relatives à la vaccination contre la grippe afin de réduire le risque d'infection et de complications au sein des populations vulnérables dont ils s'occupent. Les programmes d'éducation à l'intention des TS et de la population devraient traiter des doutes qui circulent concernant le risque de maladie chez les TS, leur famille et les patients, l'efficacité du vaccin et ses effets secondaires.

La recommandation faite par un professionnel de la santé joue un rôle majeur dans la décision de se faire vacciner. La plupart des sujets à risque élevé sont déjà suivis par un médecin et devraient être vaccinés à l'automne, lors d'une consultation régulière. Au nombre des stratégies qui permettent d'accroître la couverture vaccinale de la population, mentionnons les suivantes :

* Mise en place de politiques permanentes dans les établissements permettant aux infirmières d'administrer le vaccin, et vaccination simultanée du personnel et des résidents des maisons de soins infirmiers et des ESLD. Dans ces milieux, les taux de vaccination sont plus élevés

* lorsqu'un seul employé autre qu'un médecin organise le programme;

* lorsqu'il existe des politiques écrites portant sur les divers aspects du programme;

* lorsqu'on adopte une politique visant à obtenir, au moment de l'admission, un consentement valable pour les années ultérieures.

* Vaccination des personnes à risque élevé au moment de leur congé de l'hôpital ou d'une consultation aux urgences.
* Promoting influenza vaccination in clinics in which high-risk groups are seen (e.g., cancer clinics, cardiac clinics, pulmonary clinics, obstetrics clinics).

* Using community newspapers, radio, television, other media and influenza information lines, and collaborating with pharmacists and specialist physicians to distribute information about the benefits and risks of influenza immunization.

* Issuing computer-generated reminders to HCWs, mailing reminder letters to patients or using other recall methods to identify outpatients at high risk.

* Issuing patient-carried reminder cards.

* Increasing the accessibility of immunization clinics for staff in institutions and for community-based elderly (e.g., mobile programs).

* Organizing activities such as vaccination fairs and competitions between institutions.

* Working with multicultural groups to plan and implement effective programs.

* Incorporating influenza vaccination within the provision of home health care.

* Promotion de la vaccination antigrippale dans les cliniques fréquentées par les groupes à risque élevé (p. ex. cliniques d'oncologie, de cardiologie, de pneumologie ou d'obstétrique).

* Recours aux journaux de quartier, à la radio, à la télévision et aux autres médias ainsi qu'aux lignes d'information sur la grippe, et collaboration avec les pharmaciens et les médecins spécialistes pour la diffusion d'information sur les avantages et les risques de la vaccination antigrippale.

* Envoi de rappels électroniques aux TS, envoi par la poste de lettres de rappel aux patients ou utilisation d'autres méthodes de relance pour l'identification des consultants externes à risque élevé.

* Distribution de cartes de rappel que les patients portent sur eux.

* Amélioration de l'accès du personnel des établissements et des personnes âgées vivant dans la collectivité aux séances de vaccination (p. ex. par la mise en œuvre de programmes itinérants).

* Organisation d'activités, telles que des foires de vaccination et des concours de vaccination entre établissements.

* Travail auprès de différents groupes culturels en vue de la planification et de la mise en œuvre de programmes efficaces.

* Intégration de la vaccination antigrippale dans les soins dispensés à domicile.

## VI. Immunization of Health Care Workers

Influenza vaccination provides benefits to health care workers (HCWs) and to the patients they care for. Unfortunately vaccine uptake in HCWs often falls short of expectations. Coverage rates for residents of long-term care facilities (LTCFs) range from 70% to 91%.(176)-(178) Studies of HCWs in hospitals and LTCFs reveal influenza vaccination coverage rates of 26% to 61%. According to the 2006 Adult National Immunization Coverage Survey, coverage rates are higher among those in close contact with patients (69.7%, 95% CI: 66.8-72.6, n=727) (unpublished data, Immunization and Respiratory Infections Division, PHAC).

Transmission of influenza between infected HCWs and their vulnerable patients results in significant morbidity and mortality. Studies have demonstrated that HCWs who are ill with influenza frequently continue to work, thereby potentially transmitting the virus to both patients and co-workers. In one study, 59% of HCWs with serologic evidence of recent influenza infection could not recall having influenza, suggesting that many HCWs experience subclinical infection.(179) These individuals continued to work, potentially transmitting infection to their patients. In two other studies, HCWs reported four to ten times as many days of respiratory illness as days absent from work due to respiratory illness, suggesting that many HCWs worked while they were ill and were potentially able to transmit infection.(126),(180) In addition, absenteeism of HCWs who are sick with influenza results in excess economic costs and, in some cases, potential endangerment of health care delivery because of the scarcity of replacement workers.

## VI. Immunisation des travailleurs de la santé

La vaccination contre la grippe apporte des bienfaits tant aux travailleurs de la santé (TS) qu'aux patients dont ils prennent soin. Malheureusement, le nombre de TS qui se font vacciner est souvent bien inférieur au nombre attendu. Les taux de couverture chez les résidents d'établissements de soins de longue durée (ESLD) varient entre 70 % et 91 % (176)-(178). Des études portant sur les TS en milieu hospitalier et dans les ESLD montrent que les taux de couverture vaccinale contre la grippe se situent entre 26 % et 61 %. Selon l'Enquête nationale sur la vaccination des adultes de 2006, les taux de couverture sont supérieurs chez ceux qui travaillent en contact direct avec les patients (69,7 %, IC à 95 % : 66,8-72,6, n = 727) (données non publiées, Division de l'immunisation et des infections respiratoires, ASPC).

La transmission de la grippe entre des TS infectés et leurs patients vulnérables est à l'origine d'une morbidité et d'une mortalité importantes. Des études ont démontré que les TS atteints de la grippe continuent souvent à travailler et peuvent ainsi transmettre le virus de la grippe aux patients comme à leurs collègues. Dans une étude, 59 % des TS dont les résultats aux tests sérologiques indiquaient une grippe récente ne se rappelaient pas avoir été malades, ce qui donne à penser que nombre d'entre eux avaient eu une infection subclinique(179). Ces personnes ont continué à travailler, risquant ainsi de transmettre l'infection à leurs patients. Dans deux autres études, les TS ont signalé 4 à 10 fois plus de journées de maladie respiratoire que de journées d'absence du travail en raison d'une maladie respiratoire, ce qui donne à penser que de nombreux TS avaient travaillé alors qu'ils étaient malades et pouvaient potentiellement transmettre l'infection(126),(180). De plus, l'absentéisme des TS atteints de la grippe entraîne des coûts économiques supplémentaires et, dans certains cas, pourrait compromettre la prestation de soins de santé en raison de la pénurie de travailleurs de remplacement.
Four randomized controlled trials conducted in long-term care settings have demonstrated that vaccination of HCW staff is associated with substantial decreases in mortality in the residents. Potter et al.⁽¹²¹⁾ found that vaccination of HCWs in geriatric medical long-term care sites was associated with reductions of total patient mortality from 17% to 10% (OR 0.56, 95% CI: 0.40-0.80) and in influenza-like illness (OR 0.57%, 95% CI: 0.34-0.94) Vaccination of patients was not associated with significant effects on mortality. Carman et al.⁽¹²³⁾ studied 20 long-term elderly-care hospitals and found 13.6% patient mortality in hospitals where influenza vaccine was given to staff compared with 22.4% in no-vaccine hospitals (OR 0.58, 95% CI: 0.40-0.84, *p*=0.014). Hayward et al.⁽¹²⁰⁾ found significant decreases in resident mortality in the first study year in U.K. care homes where influenza vaccine was offered to staff compared with non-intervention homes (rate difference: -5.0 per 100 residents, 95% CI: -7.0 to -2.0) and in influenza-like illness (ILI) (*p*=0.004), GP ILI consultations (*p*=0.008) and in hospital admissions with ILI (P=0.009). No differences were found during periods of no influenza activity or in a second study year. Lemaitre et al.⁽¹²⁴⁾ studied 40 nursing homes and found 20% lower resident mortality (*p*=0.02) in homes where influenza vaccine was provided to staff compared with control homes, and a strong correlation was observed between staff vaccination coverage and all cause mortality in residents (correlation coefficient=0.42, *p*=.007). In the vaccination arm, ILI in residents was 31% lower (*p*=.007) and staff sick leave was 42% lower (*p*=.03). A Cochrane review of studies in long-term care settings reported that pooled data from three cluster randomized controlled trials showed that vaccination of health care workers in long-term care facilities for the elderly reduced influenza-like illness (OR 0.71, 95% CI: 0.55-0.90, *p*=.005) and all cause mortality (OR 0.68, 95% CI: 0.55-0.84, *p*<.001).⁽¹⁸¹⁾ The review also mentions that no effect was shown in the elderly for other outcomes such as laboratory-proven influenza and death from pneumonia.

For the purposes of this document, we define a HCW as a person who provides direct patient care or indirect health services. The term "direct patient contact" is defined as activities that allow opportunities for influenza transmission between HCWs and a patient.

NACI considers the provision of influenza vaccination for HCWs who have direct patient contact to be an essential component of the standard of care for the protection of their patients. HCWs who have direct patient contact should consider it their responsibility to provide the highest standard of care, which includes annual influenza vaccination. In the absence of contraindic-

Quatre essais comparatifs randomisés effectués dans des établissements de soins de longue durée ont révélé que la vaccination des TS est associée à des baisses importantes de la mortalité chez les résidents. Potter et coll.⁽¹²¹⁾ ont constaté que la vaccination des TS dans des centres de soins gériatriques de longue durée était associée à des réductions de la mortalité totale chez les patients, qui est passée de 17 % à 10 % (RC 0,56, IC à 95 % : 0,40-0,80), et des taux de syndrome grippal (RC 0,57 %, IC à 95 % : 0,34-0,94). La vaccination des patients n'était pas associée à des effets significatifs sur la mortalité. Carman et coll.⁽¹²³⁾ ont étudié 20 hôpitaux de soins de longue durée pour personnes âgées et ont obtenu des taux de mortalité de 13,6 % chez les patients d'hôpitaux où le vaccin contre la grippe avait été administré au personnel comparativement à 22,4 % dans les hôpitaux où il n'y avait pas eu de vaccination (RC 0,58, IC à 95 % : 0,40-0,84, *p* = 0,014). Hayward et coll.⁽¹²⁰⁾ ont observé des diminutions importantes de la mortalité chez les résidents durant la première année de leur étude dans des maisons de soins du R.-U. où le vaccin contre la grippe avait été offert aux employés comparativement au taux dans les maisons où le personnel n'avait pas été immunisé (différence dans les taux : -5,0 pour 100 résidents, IC à 95 % : -7,0 à -2,0) ainsi qu'une baisse significative des taux de syndrome grippal (SG) (*p* = 0,004), des consultations chez un omnipratien pour un SG (*p* = 0,008) et d'hospitalisation pour un SG (P = 0,009). Aucune différence n'a été relevée durant les périodes d'absence d'activité grippale ou durant la deuxième année d'étude. Lemaitre et coll.⁽¹²⁴⁾ ont examiné 40 maisons de soins infirmiers et constaté que les taux de mortalité chez les résidents étaient 20 % inférieurs (*p* = 0,02) dans les maisons où le personnel avait été vacciné que dans les maisons-témoins, et qu'il existait une corrélation étroite entre la couverture vaccinale des employés et la mortalité toutes causes confondues chez les résidents (coefficient de corrélation = 0,42, *p* = 0,007). Dans les centres où le personnel avait été vacciné, le taux de SG chez les résidents était 31 % plus faible (*p* = 0,007) et le personnel avait pris 42 % moins de congés de maladie (*p* = 0,03). Une recension des études dans les établissements de longue durée effectuée par la Cochrane Collaboration a indiqué que les données regroupées de trois essais comparatifs randomisés portant sur des grappes de cas démontraient que la vaccination des travailleurs de la santé dans les établissements de soins de longue durée pour personnes âgées réduisait le taux de syndrome grippal (RC 0,71, IC à 95 % : 0,55-0,90, *p* = 0,005) et la mortalité toutes causes confondues (RC 0,68, IC à 95 % : 0,55-0,84, *p* < 0,001)⁽¹⁸¹⁾. La revue indique également qu'aucun effet n'a été démontré chez les personnes âgées en ce qui concerne d'autres résultats, tels que les cas d'influenza confirmés en laboratoire ou les décès dus aux pneumonies.

Pour les besoins du présent document, un TS est une personne qui dist pense des soins directs aux patients ou des services de santé indirects. Le terme « soins directs aux patients » renvoie aux activités au cours desquelles la transmission de la grippe entre les TS et les patients est possible.

Le CCNI estime que l'administration du vaccin antigrippal aux TS qui ont des contacts directs avec les patients constitue un élément essentiel des normes de conduite pour la protection des patients. Les TS ayant des contacts directs avec les patients doivent considérer qu'ils ont la responsabilité de fournir des soins de la meilleure qualité possible et, par conséquent, de se faire vacciner chaque année contre la grippe. En l'absence
ations, refusal of HCWs who have direct patient contact to be immunized against influenza implies failure in their duty of care to patients.

In order to protect vulnerable patients during an outbreak, it is reasonable to exclude from direct patient contact HCWs with confirmed or presumed influenza and unvaccinated HCWs who are not receiving antiviral prophylaxis. Health care organizations should have policies in place to deal with this issue.

de contre-indications, leur refus de se faire vacciner peut être assimilé à un manquement à leur obligation de diligence envers leurs patients.

Pour protéger les patients vulnérables durant une éclosion, il est raisonnable de les empêcher d'avoir des contacts directs avec les TS qui développent une grippe confirmée ou présumée et avec les TS qui ne sont pas vaccinés et ne reçoivent pas de traitement prophylactique antiviral. Les organisations de soins de santé devraient avoir en place des politiques à cet égard.
## VII References

(1) Shaw MW, Xu X, Li Y et al. Reappearance and global spread of variants of influenza B/Victoria/2/87 lineage viruses in the 2000-2001 and 2001-2002 seasons. Virology. 2002;303(1):1-8.

(2) Levandowski RA, Gross PA, Weksler M et al. Cross-reactive antibodies induced by a monovalent influenza B virus vaccine. J Clin Microbiol. 1991;29(7):1530-2.

(3) Heckler R, Baillot A, Engelman H et al. Cross-protection against homologous drift variants of influenza A and B after vaccination with split vaccine. Intervirology. 2007;50(1):58-62.

(4) Walter EB, Neuzil KM, Zhu Y et al. Influenza vaccine immunogenicity in 6 to 23-month-old children: are identical antigens necessary for priming? Pediatrics. 2006;118:e570-8.

(5) Englund JA, Walter EB, Gbadebo A et al. Immunization with trivalent inactivated influenza vaccine in partially immunized toddlers. Pediatrics. 2006;118(3):e579-85.

(6) Levandowski RA, Regnery HL, Staton E et al. Antibody responses to influenza B viruses in immunologically unprimed children. Pediatrics. 1991;88(5):1031-6.

(7) World Health Organization. Recommended composition of influenza virus vaccines for use in the 2010-2011 northern hemisphere influenza season. Wkly Epidemiol Rec. 2010;85(10):81-92. Available from: http://www.who.int/wer/2010/wer8510.pdf.

(8) Reyes F, Macey JF, Aziz S et al. Influenza in Canada: 2005-2006 season. Can Commun Dis Rep. 2007;33 (3):21-41.

(9) National Advisory Committee on Immunization (NACI). Statement on seasonal trivalent inactivated influenza vaccine (TIV) for 2009-2010. Can Commun Dis Rep. 2009;35(ACS-6):1-41.

(9a) Helferty M, Vachon J, Tarasuk J, et al. Canadian pandemic H1N1 2009 cases: a description of the changing epidemiology of hospitalizations and deaths in the first and second waves. CMAJ 2010;182; In press.

(10) Campbell A, Rodin R, Kropp R et al. Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza. CMAJ. 2010;182:349-55.

(11) Bettinger JA, Sauvé LJ, Scheifele DW et al. Pandemic influenza in Canadian children: a summary of hospitalized pediatric cases. Vaccine. 2010;28:3180-4.

(12) Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza. Clinical aspects of pandemic 2009 influenza A (H1N1) infection. N Engl J Med. 2010;362:1708-19.

## VII Références

(1) Shaw MW, Xu X, Li Y, et coll. Reappearance and global spread of variants of influenza B/Victoria/2/87 lineage viruses in the 2000-2001 and 2001-2002 seasons. Virology 2002;303(1):1-8.

(2) Levandowski RA, Gross PA, Weksler M et coll. Cross-reactive antibodies induced by a monovalent influenza B virus vaccine. J Clin Microbiol 1991;29(7):1530-2.

(3) Heckler R, Baillot A, Engelman H, et coll. Cross-protection against homologous drift variants of influenza A and B after vaccination with split vaccine. Intervirology 2007;50(1):58-62.

(4) Walter EB, Neuzil KM, Zhu Y, et coll. Influenza vaccine immunogenicity in 6 to 23-month-old children: are identical antigens necessary for priming? Pediatrics 2006;118:e570-e578.

(5) Englund JA, Walter EB, Gbadebo A, et coll. Immunization with trivalent inactivated influenza vaccine in partially immunized toddlers. Pediatrics 2006;118(3):e579-e585.

(6) Levandowski RA, Regnery HL, Staton E, et coll. Antibody responses to influenza B viruses in immunologically unprimed children. Pediatrics 1991;88(5):1031-6.

(7) Organisation mondiale de la santé. Recommended composition of influenza virus vaccines for use in the 2010-2011 northern hemisphere influenza season. Wkly Epidemiol Rec 2010;85(10): 81-92. Affiché à : http://www.who.int/wer/2010/wer8510.pdf.

(8) Reyes F, Macey JF, Aziz S, et coll. La grippe au Canada : saison 2005-2006. Relevé des maladies transmissibles au Canada 2007;33(3):21-41.

(9) CCNI. Déclaration sur le vaccin antigrippal trivalent inactivé (VTI) pour la saison 2009-2010. Relevé des maladies transmissibles au Canada 2009;35(ACS-6):1-41.

(9a) Helferty M, Vachon J, Tarasuk J, et al. Canadian pandemic H1N1 2009 cases: a description of the changing epidemiology of hospitalizations and deaths in the first and second waves. CMAJ 2010;182; In press.

(10) Campbell A, Rodin R, Kropp R, et coll. Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza. CMAJ 2010;182:349-355.

(11) Bettinger JA, Sauvé LJ, Scheifele DW, et coll. Pandemic influenza in Canadian children: a summary of hospitalized pediatric cases. Vaccine 2010;28:3180-4

(12) Comité de rédaction du Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza de l'Organisation mondiale de la santé. Clinical aspects of pandemic 2009 influenza A (H1N1) infection. N Engl J Med 2010;362:1708-19.
(13) WHO. Pandemic (H1N1) 2009—update 105. Available from: http://www.who.int/csr/don/2010_06_18/en/index.html.

(14) Australian Influenza Surveillance Report No. 23, 2010, Reporting period 2010 Jun 5-11. Available from: http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/Content/ozflucurrent.htm.

(15) New Zealand Ministry of Health. Influenza Weekly Update 2010/23: 2010 Jun 7-13. Available from: http://www.surv.esr.cri.nz/virology/influenza_weekly_update.php.

(16) Pan American Health Organization. Regional update pandemic (H1N1) 2009. 2010 Jun 21. Available from: http://new.paho.org/hq/index.php?option=com_content&task view&id=2929&Itemid=2295&lang=en.

(17) European Centre for Disease Prevention and Control. Surveillance report. Biweekly influenza surveillance overview 2010 Jun 22. Available from: http://ecdc.europa.eu/en/publications/Publications/100618 Sur Biweekly Influenza Surveillance Overview.pdf.

(18) Centers for Disease Control and Prevention. FluView. 2009-2010 Influenza Season Week 20 ending 2010 May 22. Available from: http://www.cdc.gov/flu/weekly/weeklyarchives2009-2010/weekly_20.htm.

(19) WHO. Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO. 2010 Jun 8. Available from: http://www.who.int/csr/disease/avian_influenza/country/cases_table_2010_06_08/en/index.html.

(20) WHO. Weekly update on oseltamivir resistance to pandemic influenza A (H1N1) 2009 viruses. 2010 Jun 16. Available from: http://www.who.int/csr/disease/swineflu/oseltamivirresistant20100618.pdf.

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(22) Smith S, Demicheli V, Di Pietrantonj C et al. Vaccines for preventing influenza in healthy children. Cochrane Database Syst Rev. 2006;2006(1):CD004879.

(23) Negri E, Colombo C, Giordano L et al. Influenza vaccine in healthy children: a meta-analysis. Vaccine. 2005;23(22):2851-61.

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(13) Organisation mondiale de la santé. Pandemic (H1N1) 2009 – update 105. Affiché à : http://www.who.int/csr/don/2010_06_18/en/index.html.

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(15) New Zealand Ministry of Health. Influenza Weekly Update 2010/23: 7-13 June 2010. Affiché à : http://www.surv.esr.cri.nz/virology/influenza_weekly_update.php.

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(20) Organisation mondiale de la santé. Weekly update on oseltamivir resistance to pandemic influenza A (H1N1) 2009 viruses. Le 16 juin 2010. Affiché à : http://www.who.int/csr/disease/swineflu/oseltamivirresistant20100618.pdf.

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