Pakistan: Suspected Human Cases December 10 - December 17, 2007

[HenryN]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Fresh outbreak of bird flu claims two lives in Pakistan, says UN agency

<LEFT><TABLE cellSpacing=0 cellPadding=2 width=120 align=left border=0><TBODY><TR><TD align=VALIGN=TOP></TD></TR><TR><TD vAlign=top align=left></TD></TR></TBODY></TABLE>17 December 2007 ? At least two Pakistanis have died in a fresh outbreak of avian influenza close to the country?s ?poultry belt,? the United Nations World Health Organization (WHO) has reported.
Pakistani health officials informed WHO of eight suspected human cases of infection with the H5N1 virus ? the virus responsible for outbreaks of bird flu around the world in recent years ? in the area around the city of Peshawar.
In an update issued at the weekend, WHO said two people have died in the outbreak and one person has now recovered.
The outbreak in humans was detected after a series of culling operations in the area in response to an outbreak of the virus in local poultry. Samples taken by health officials have tested positive in the national laboratory and are now being referred to a WHO laboratory for further analysis.
The agency is helping Pakistani health officials conduct epidemiological investigations and assess the current surveillance, prevention and control measures in place to see whether they need tightening or adjusting.
Pakistan has been hit by multiple outbreaks of bird flu in its domestic poultry population since last year, while this year there has also been outbreaks in wild birds.
WHO officials are also assisting local health authorities in Myanmar and Indonesia in response to outbreaks in those countries.
In Myanmar, a seven-year-old girl from Shan State (East) has recovered after developing symptoms of fevers and headaches last month. Samples from the case have tested positive for the H5N1 virus. Indonesian officials have confirmed that a 47-year-old man from the country?s Banten Province has bird flu and has been hospitalized since 9 December. So far, 115 human cases have been confirmed in Indonesia, and 92 have been fatal.

http://www.un.org/apps/news/story.asp?NewsID=25085&Cr=bird&Cr1=flu

[HenryN]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

agreed that there is much information missing here, including further characterization of the virus and a description of the actual tests performed.

There is a Bloomberg story that should be out shortly and it will have more info on Tamiflu treatment and testing.

[camster]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

yes, source of sample is very important to know. seeing infection in the upper respiratory tract would be cause for concern.

I think it's hard to predict some of your assumptions below w/o working with the virus somewhat. given those, it would be more credible, but I would think you'd still want a lower respiratory sample to be sure.

It is important to know from where samples for testing were collected: from nasal or pharynx swabs, or via bronchoscopy or via blood sample. If were nasal samples and viral strain is a bit more adapt to replicate in low temperature environment, and in a immunological naive patient with an assumed more long viral shedding, then the test results may be more credible, or not?

[Commonground]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Dutchy, it seems to be more or less the same. Treyfish's articles talks about the husband who was sleeping outside the isolation room where the brothers were. No new patients.

[HenryN]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

AVIAN INFLUENZA, HUMAN (168): PAKISTAN
**************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Mon 17 Dec 2007
Source: The News International (Pakistan) [edited]
<http://thenews.jang.com.pk/top_story_detail.asp?Id=11770>


The Caretaker North Western Frontier Province (NWFP) Health Minister
Syed Kamal Shah expressed his dismay over the "continuous reluctance"
of the National Institute of Health (NIH) in providing the provincial
government with reports regarding the bird flu victims. Setting a
24-hour deadline to the NIH for releasing the report, he said that
the institute's denial or delay would be taken as they were hiding
the report for vested interests. Besides, Syed Kamal said that the
NWFP government was seriously considering closing down the poultry
business in the Frontier province. The Minister said 70 percent of
Pakistan's poultry industry was based in the 2 districts of the NWFP,
including Abbottabad and Mansehra, which he felt had been posing
serious threat to the lives of the local population.

It may be recalled that after the deaths of 2 brothers at the Khyber
Teaching Hospital (KTH) in Peshawar on 19 and 29 Oct [2007]
respectively, 3 more patients suffering from bird flu virus were
admitted to hospitals in Abbottabad and Peshawar.

In Ayub Medical Complex (AMC), Abbottabad, where 2 patients, [a 38
year old man] and a 10 year old girl, were admitted, doctors said
their condition was stable and they were sent home. Medical
Superintendent AMC Dr Iftikhar, when reached on telephone, told 'The
News' one of them was working at a poultry farm in Abbottabad while
the girl was living in the vicinity of the farm. "Their blood samples
had been sent to the NIH but the report is awaited," he said. Another
patient, who belongs to the nearby Palosai town, was admitted to the
KTH.

Dr Mukhtiar Zaman Afridi, who is a noted chest physician and in
charge of Pulmonology ward of the hospital, when contacted on
telephone said the patient was in a stable condition and his blood
samples had been sent to the NIH. Also, he said the report was
expected to be made available to them today [Mon 17 Dec 2007]). He
said the patient had been kept in an isolation room and was under his
personal observation. However, during a visit to the hospital (KTH)
on Sunday [16 Dec 2007], a number of doctors and health workers
complained to this correspondent that there was a mechanism to keep
them safe from the virus but the ventilator of the isolation room
where the patient had been kept was open and the virus could spread
around in the entire hospital through air. Also, this scribe found Dr
Mukhtiar Zaman Afridi was removing fears from the mind of his staff
created after the death of 2 brothers under their observation. The
majority of doctors, paramedics, and nurses were reluctant to go into
the isolation room to attend the patient.

However, Dr Mukhtiar's lecture persuaded his staff to continue
attending this altogether different patient. Despite being a public
holiday, Dr Mukhtiar was seen present in the hospital from early
morning to the evening where he regularly examined the patient.

It was dismal to note that the 2 isolation rooms where the 2 brothers
were kept and later died were found locked by the hospital
administration. Also, despite the passage of 2 weeks, the KTH
administration has failed to ensure sterilisation of equipment used
in attending the 2 brothers.

[Byline: Mushtaq Yusufzal]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[This report provides some dates and expresses local frustration at
the tardiness of the National Institute of Health of Pakistan in
communicating the results of diagnostic tests.

Two other suspected H5N1 cases have been admitted to hospital in
Abbottabad, one a poultry worker and the other a young girl living
near a farm. These cases further strengthen the link between human
infection and poultry and reduce the probability in this outbreak of
transmission of the virus by human-to-human transmission.

A map of the NWFP of Pakistan showing the poultry rearing areas of
Abbottabad and Mansehra can be accessed at
<http://encarta.msn.com/map_701515199/North-West_Frontier.html>. - Mod.CP]

[see also:
Avian influenza, human (167): Pakistan 20071216.4049
Avian influenza, human (166): Pakistan, WHO 20071215.4038
Avian influenza, human (165): Pakistan 20071214.4023
Avian influenza, human (163): Pakistan 1st report 20071213.4008]
...................................cp/mj/lm

[HenryN]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

WHO: Bird flu is on the move again
Pakistan is reporting new infections and Myanmar has its first human case
The Associated Press
updated 1:51 p.m. ET, Mon., Dec. 17, 2007
<SCRIPT language=javascript> function UpdateTimeStamp(pdt) { var n = document.getElementById("udtD"); if(pdt != '' && n && window.DateTime) { var dt = new DateTime(); pdt = dt.T2D(pdt); if(dt.GetTZ(pdt)) {n.innerHTML = dt.D2S(pdt,(('false'.toLowerCase()=='false')?false :true));} } } UpdateTimeStamp('633335142890430000');</SCRIPT>
HANOI, Vietnam - The World Health Organization warned Monday that countries should be on alert for bird flu because it is again on the move, with Pakistan reporting new infections and Myanmar logging its first human case.
"The key to the public health response is surveillance," said Peter Cordingley, spokesman for the WHO Western Pacific region in Manila. "If we do actually get to the cases with antivirals early on, the health outcome is a lot better."
WHO experts arrived in Pakistan to try to sort out cases reported there, South Asia's first human infections. They were expected to visit a hospital and affected areas Tuesday, said WHO country representative Khalif Bile in Islamabad.
"They are here to get more information and to provide more support in the case of any potential risk," he said, adding that the Health Ministry, Agriculture Ministry and WHO are now working closely together following a "communication gap" when the government did not immediately report suspected cases to the WHO.
Four brothers and two cousins fell ill last month in Abbotabad, a small city north of Islamabad, while three others who slaughtered poultry in the same area and a nearby town tested positive for the H5N1 bird flu virus earlier this month.
Two of the brothers died, but specimens were collected from only one.
The cases were positive for H5N1 in initial government testing, but WHO will conduct further analysis to confirm the results.
Human-to-human transmission not ruled out
WHO spokesman Gregory Hartl in Geneva said Sunday human-to-human transmission had not been ruled out, but added that poultry outbreaks had earlier been reported in the area and it was unclear if all patients had links to sick birds or infected surroundings.
A doctor who cared for the brothers also experienced mild flu-like symptoms, but more testing needs to be carried out to determine if she was infected, Hartl said.
Two poultry farms near Abbotabad have been closed and health workers are taking temperatures of those living in the affected area twice a day, but no new suspected cases have been reported, said Minhajul Haq, a district health officer.
"We are on high alert, though we still await any confirmation of human-to-human transmission," he said.
At least 208 people have died from the virus, which began plaguing Asian poultry stocks in late 2003. It remains hard for people to catch, but scientists worry it could mutate into a form that spreads easily among people, potentially sparking a pandemic.
With fresh poultry outbreaks reported in a number of countries, including Germany over the weekend, WHO urged nations to be vigilant in identifying and reporting cases in both birds and humans.
93 have died so far in Indonesia
Myanmar's first human case was reported Friday in a 7-year-old girl who fell ill last month and survived, while Indonesia, the country hardest hit by the virus, has announced its 93rd death from the virus.
Two human cases were also recently confirmed in China, one of whom died.

The H5N1 virus often flares during the winter months. In some countries, like Indonesia, poultry outbreaks and human cases are reported year round, but many countries experience a flurry of activity when temperatures drop.
"It starts to pop at this time of the year, not just in this region where it's endemic, but it starts to appear in the West," Cordingley said. "Between now and April is a very dangerous time of the year."
Most human bird flu cases have been linked to sick birds, but experts suspect limited person-to-person transmission may have occurred in a few cases involving blood relatives.
URL: http://www.msnbc.msn.com/id/22299077/
<HR>

[sharon sanders]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Published online <abbr class="published" title="2007-12-17T19:15:17Z">17 December 2007</abbr> | Nature | doi:10.1038/news.2007.383
News
Large bird flu cluster emerges

Human cases in Pakistan could hint of person-to-person spread.
Declan Butler
<!-- --> Punchstock
A team of experts from the World Heath Organization (WHO) is making its way north in Pakistan to investigate a cluster of at least eight cases of avian flu in people living near the Afghan border. They will be seeking to establish whether the disease is spreading, and whether the cases were caused by human-to-human transmission.
Cases of bird flu continue to occur worldwide, mostly in Indonesia, and this is the colder time of year when flu is expected to hit hardest in the northern hemisphere. But this latest outbreak is worrying in that it involves the biggest batch of closely related cases since a cluster of eight infected people was reported in Indonesia in May 2006.
"So far, we are not seeing anything different than in previous instances of H5N1 outbreaks," says Gregory Hartl, a spokesman for WHO, whose current information comes from Pakistani authorities.
The Pakistan cases started in mid-November, or possibly earlier, when five family members fell ill in Abbottabad, north of Islamabad. Two of the brothers have died, one of whom was buried before he could be tested for H5N1.
In December, a man and his niece in the same town were found to have H5N1. They are thought to have worked on the same farm as the first family affected. Another man was found to have H5N1 in a nearby town some distance from there. Another case is suspected but not yet confirmed, which would bring the cluster to nine.
Pakistan has had repeated outbreaks of avian flu in poultry over the past two years.
On the track

The WHO team will be tracking down, treating and testing people who came into contact with the infected cases. Monitoring for cases in the area will be key to establishing whether the virus has become more virulent or shows signs of spreading.
Meanwhile, Pakistani health authorities are poring over hospital records from the past few months to see, retrospectively, whether there has been any upsurge in the incidence of respiratory illnesses.


Human-to-human transmission cannot be ruled out, says Hartl, as it has occurred on a limited basis on several occasions in the past. Tests of 40 people who have had contact with the patients have so far all turned up negative. Genetic sequencing will help to pin down the mode of transmission and whether any important genetic changes have occurred in the virus.
Early warning

The Pakistan cluster highlights the obstacles faced by the WHO in containing the spread should a pandemic strain of H5N1 appear. The strategy calls for early diagnosis of cases, in the hope that blanket treatment with antivirals will stamp out an emerging pandemic before it spirals out of control. Computer models suggest that for this to have any chance of succeeding, WHO would have a window of three weeks for this diagnosis at most.

But although the first cases occurred in mid-November at the latest, Pakistan only officially informed WHO on 12 December, a day after the first media reports. WHO made the cases public on 15 December. (actually the first media reports were Dec. 10 - check the date of this thread- Fla1)


Last Friday, the WHO also confirmed the first case in Myanmar: a 7-year old girl from Kyaing Tone Township, Shan State, who was hospitalized in late November, and has since recovered. A WHO team has so far found no evidence of infections in any of the case's contacts or in the area.

http://www.nature.com/news/2007/071217/full/news.2007.383.html

<!-- end .entry-content -->

[sharon sanders]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Today I received this statement in my email from the CDC and I have permission to quote:

"From CDC,

There are no reports of animal or human avian influenza A (H5N1) infections in the United States.

• On December 7, 2007, the Centers for Disease Control and Prevention (CDC) was notified by the New York State Department of Health about a man in Nassau County, New York who had recently returned from Pakistan and who had contact with a person suspected of having been infected with avian influenza.

• The contact has since tested negative for influenza, H5 at the New York State Department of Health. This negative test result was confirmed at CDC by real-time reverse-transcriptase polymerase chain reaction (rtRT-PCR test).

• Upon returning from Pakistan to the United States, the contact was hospitalized for observation on December 6 and discharged on December 7. Voluntary home quarantine was in place until all specimens collected tested negative for avian influenza, H5 by real-time PCR on December 9."

[AlaskaDenise]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Commentary at

http://www.recombinomics.com/News/12..._US_False.html

Commentary

False H5N1 Negatives in Pakistan and the United States?

Recombinomics Commentary
December 17, 2007

The Health Ministry said it was treating people who had been in contact with those infected, setting up isolation wards and procuring drugs for treatment and protective clothing for health workers.

The above update raises additional questions regarding the spread of H5N1 in Pakistan and the United States. Testing of samples collected after the start of Tamiflu treatment can generate false negatives, since Tamiflu reduces viral load, which is the target of PCR testing. Earlier reports indicated several H5N1 patients had mild symptoms or were asymptomatic, but registered positive on a "less reliable" test, which was likely to be an H5 antibody test. This testing may be more reliable than PCR testing for patients who have already started Tamiflu treatment. Ideally, samples would be collected before or at the start of Tamiflu treatment.

The above information raises questions about the brother (38M) who returned to the US after attending funeral(s) of his two brothers in Pakistan (see Nassua County report). Since the dates of death were ten days apart (November 19 and 29), there would be significant exposure opportunities if the visiting brother was in Pakistan for both funerals.

The Nassua report indicates the patient was prescribed Tamiflu also, but it is unclear if specimens were collected before or after the start of treatment (which may have begun in Pakistan).

More information on the testing, including follow-up tests on convalescent, serum would be useful.


.

[HenryN]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Commentary at

http://www.recombinomics.com/News/12170705/H5N1_Pakistan_Cloudy.html

[AlaskaDenise]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

<TABLE><TBODY><TR><TD>Hospitals on alert against bird flu

</TD></TR><TR><TD>Laboratories, drugs and emergency units put in order | Doctors say cooked meat safe for human consumption

</TD></TR><TR><TD>Manzoor Qadir

</TD></TR><TR><TD>LAHORE: After the conformation of eight human cases of bird flu influenza, of which two real brothers reportedly died in NWFP, for the first time in the history of country, the Punjab government has put all public hospitals on high alert to cope with any emergency arising out of H5N1 strain of avian (birds) influenza.

According to World Health Organisation, the virus has killed more than two hundred people worldwide since it began ravaging Asian poultry stocks in late 2003.

The experts say that it is difficult for people to catch the disease as the flu does not infect humans but, they fear, the virus could mutate into a form that passes easily among people, potentially sparking an epidemic that could kill millions of people. That is why the government has started taking extra ordinary steps to stop it.

Special directions have been issued to principals, medical superintendents of teaching hospitals and executive health officers (Health) for keeping surveillance and adopt recommended measures for preventing any outbreak of avian influenza. Isolation units that were meant during the last year in various public hospitals to house the suspected bird flu victims have been reactivated while medicines and diagnostic kits have been provided to the hospitals in this regard.

Talking to The Post, WHO representative to Punjab, Dr Asmatullah Chaudhry said in the wake of threat posed by H5N1, special instructions had been issued to the EDOs to keep constant vigil on the situation.

"The viral transport medium required for the transport of suspected human samples along with related guidelines has been dispatched to the district health departments", he added.

Moreover, special arrangements for rapid response if any case is detected in the province have been ensured while special teams constituted to collect blood samples for laboratory tests of the affected persons and to send these through TCS courier service to National Institute of Health Laboratory, he said , adding that besides EDO (Health), Executive District Officers (Agriculture), District Officers Forests and District Officers Livestock had been asked to reactivate surveillance to identify and isolate the viruses causing bird flu.

They have been directed to monitor the situation in their respective districts and to report swiftly any suspected case of bird flu in Punjab.

More diagnostic tests would be conducted at the Veterinary Research Institute (VRI) Lahore and Poultry Research Institute (PRI) Rawalpindi in this regard, he notified.

Eastern Mediterranean Region of World Health Organization (EMRO-WHO) Advisor on Infectious Diseases Dr Akbar Chaudhry said that most human cases had so far been linked to contact made with sick birds while this was very early to determine if the virus could have been transmitted through human contact in the case of two brothers' death.

""I can not answer that yet, it is possible, if the man to man transmission of H5N1 will be confirmed in the cases of NWFP, it will be pandemic situation for the country," he worried. He said that mortality rate owing to H5NI strain is as high as 70 per cent among the humans.

Dr Akbar Chaudhry, who is also one of the eight members of WHO's Task Force on Bird Flu, said that only 272 cases of birds to human transmission of H5N1 virus and just 4 cases of human to human transmission all over the world were reported since 2003 while about 210 H5N1 affected patients had died to-date.

Indonesia, Malaysia, Philippine, China, Vietnam, Egypt and South Asian Estates are among the bird flu affected countries, he pointed out.

He observed that migratory birds from Russia, Siberia, Mongolia, China, Kazakhstan, etc., were major source of bird flu transmission among poultry products and other domestic birds in Pakistan, which needed to be protected through preventive measures and vaccination among poultry and domestic birds. He said that there was a need to adopt precautionary measures by vulnerable people like poultry handlers, transporters, butchers and the buyers to avoid transmission of H5N1 virus. However, he said that the cooked chicken was absolutely safe for consumption because anything cooked at 70 degrees, which usually was a practice in our households, destroyed H5N1 virus in the meat.

</TD></TR></TBODY></TABLE>

http://thepost.com.pk/CityNews.aspx?dtlid=134605&catid=3

[AlaskaDenise]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Commentary at

http://www.recombinomics.com/News/12...an_Cloudy.html

<TABLE style="WIDTH: 775px; COLOR: rgb(190,5,1); FONT-FAMILY: helvetica,arial,sans-serif; TEXT-ALIGN: left" cellSpacing=0 cellPadding=0 border=0><TBODY><TR><TD style="VERTICAL-ALIGN: top; WIDTH: 40px">
</TD><TD style="VERTICAL-ALIGN: top; WIDTH: 515px" colSpan=5><BIG><BIG>Commentary</BIG></BIG>

Details on H5N1 Transmission in Pakistan Remain Cloudy

Recombinomics Commentary
December 17, 2007

The Pakistan cases started in mid-November, or possibly earlier, when five family members fell ill in Abbottabad, north of Islamabad. Two of the brothers have died, one of whom was buried before he could be tested for H5N1.

In December, a man and his niece in the same town were found to have H5N1. They are thought to have worked on the same farm as the first family affected. Another man was found to have H5N1 in a nearby town some distance from there. Another case is suspected but not yet confirmed, which would bring the cluster to nine.

The above comments from a Nature story by Declan Butler provide additional detail to the H5N1 cluster(s) in Pakistan, but don?t clear up the many contradictions. Some of the media reports are quite precise on dates, indicating the outbreak links back to a poultry cull on October 21-23. A veterinarian was the index case, who developed symptoms on October 25. Forty samples were collected on or about October 30, and at least four were said to be positive. Two brothers of the index case were students, and they died November 19 and 29. A third brother, a student, also tested positive, but recovered. Two more relatives (originally described as two cousins, but updated to a cousin and another brother), also tested positive, but had mild symptoms.

A sixth brother, residing in Nassau County, New York, was in Pakistan for the funerals. He returned to New York December 5 and tested negative, but WHO media quotes indicated he had mild respiratory disease symptoms, while the report from New York indicated he was asymptomatic. Since he did not return until December 5, it seems likely he was receiving Tamiflu prior to testing, which may have generated a false negative.

Similarly, there is contradictory data on a health care worker. Media reports indicated she tested positive, but was asymptomatic. A subsequent media report indicated she had mild symptoms, but test results were pending.

Thus, key data on disease onset symptoms as well as disease onset dates, remain confused, at best.

Clarification of these issues would be useful. Human-to-human transmission appears to be likely, but the length of the transmission chain and contacts in the chain, remain very much confused.

</TD></TR></TBODY></TABLE>
.

[Vibrant62]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

<TABLE><TBODY><TR><TD>Hospitals on alert against bird flu

snip

Eastern Mediterranean Region of World Health Organization (EMRO-WHO) Advisor on Infectious Diseases Dr Akbar Chaudhry said that most human cases had so far been linked to contact made with sick birds while this was very early to determine if the virus could have been transmitted through human contact in the case of two brothers' death.

""I can not answer that yet, it is possible, if the man to man transmission of H5N1 will be confirmed in the cases of NWFP, it will be pandemic situation for the country," he worried. He said that mortality rate owing to H5NI strain is as high as 70 per cent among the humans.

Dr Akbar Chaudhry, who is also one of the eight members of WHO's Task Force on Bird Flu

snip</TD></TR></TBODY></TABLE>

http://thepost.com.pk/CityNews.aspx?...134605&catid=3

He is clearly concerned at the possibility of h2h, to be placed on record in an interview as saying this. Has a similar statement been made within WHO official communications as yet, or is this merely an expression of his personal concern?

[AlaskaDenise]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Sorry for the disappearing story. I moved a copy to the India thread, but restored the post here.

.

[Sally Furniss]

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Today I received this statement in my email from the CDC and I have permission to quote:

"From CDC,

There are no reports of animal or human avian influenza A (H5N1) infections in the United States.

• On December 7, 2007, the Centers for Disease Control and Prevention (CDC) was notified by the New York State Department of Health about a man in Nassau County, New York who had recently returned from Pakistan and who had contact with a person suspected of having been infected with avian influenza.

• The contact has since tested negative for influenza, H5 at the New York State Department of Health. This negative test result was confirmed at CDC by real-time reverse-transcriptase polymerase chain reaction (rtRT-PCR test).

• Upon returning from Pakistan to the United States, the contact was hospitalized for observation on December 6 and discharged on December 7. Voluntary home quarantine was in place until all specimens collected tested negative for avian influenza, H5 by real-time PCR on December 9."

This is the release we have been waiting for?