A travel history to any country which reported confirmed cases was notified along with the age of the patient. Those with a travel history within 10 days preceding the onset were regarded as imported cases. Comparison of age between those with and without a travel history was performed using the Welch test. Of 4,986 confirmed cases, 903 (18.1%) were imported. Figure 1 compares the age distribution between imported www.selleckchem.com/screening/chemical-library.html and indigenous cases. The mean (SD) and median ages of imported cases were 27.0 (15.6) and 26.0 years, and of indigenous cases were 17.6 (10.9) and 16.0 years. The age of imported cases appeared to be significantly

older than indigenous cases (p < 0.01). While 83.4% of indigenous cases were aged <25 years, only 43.4% of imported cases were <25 years. The risk of infection among imported cases was not found to be accumulated in those aged <20 years, but rather those aged 25 years and older accounted for more than half of the imported infections. The differential age distribution most likely reflected age-specific travel patterns because adults >25 years were more likely to have experienced international travel. An important limitation of the present study is that imported case, which was defined as those with a travel history within 10 days before the illness onset, potentially includes those infected in Japan. Nevertheless, given the significantly

different ages between crudely defined imported and indigenous cases, the age of actual imported cases may be even older than that reported

in Figure 1. As a future subject, in addition to the age-specific Protein Tyrosine Kinase inhibitor Glutamate dehydrogenase absolute number of cases, age-specific incidence of infection among travelers (ie, imported cases divided by the number of travelers) needs to be explored. Whereas the impact of imported cases on the transmission dynamics of importing country can be partly assessed by examining the age-specific number of imported cases,7,8 further clarification of the role of adults in accelerating global spread requires additional insight into the age-specific risk of infection among travelers.9 Epidemiological analysis of travel-associated cases of H1N1 2009 influenza is crucial for understanding the dynamics of international spread and elucidating the most effective strategies for disease control.10 Unlike the local spread of H1N1 2009 influenza, which is frequently driven by infection in schoolchildren, adults play an important role in accelerating international spread. Adults are also likely to be the source of interregional spread within a country. Two important implications are that prevention of international spread (eg, border controls) must not overlook the high frequency of infection even among older adults, and surveillance and monitoring of the spread of disease over long distances need to take into account the impact of age specificity of travel on geographic propagation.11 The work of H. N. was supported by the JST PRESTO program.