Announcement

Re: WHO Update on Pakistan Cluster from November/December '07

Testing confirms another two bird flu cases from cluster in Pakistan family

4 hours ago
The World Health Organization has added two more people to Pakistan's avian influenza case count, saying followup blood testing confirmed additional cases from a suspected large family cluster late last year.
Multiple members of a family were eventually tested after one, a veterinary worker involved in culling H5N1 infected chickens, fell ill and seemed to set off a chain of infection within his extended family.
H5N1 wasn't initially suspected as the cause of illness, so the veterinary worker was not tested for it when he was sick. Once the virus was identified as a possible cause of the cluster of cases, only one member of the family - the third person to get sick - tested positive.
But more laborious followup testing - performed by looking for antibodies to the virus in the blood of surviving suspect cases - showed that the veterinary worker was indeed infected with H5N1.
The most likely explanation for the cluster is limited human-to-human spread, the WHO said.
"We believe that limited human to human transmission likely occurred among some of the family members," spokesperson Gregory Hartl said Thursday in an e-mail.
"This is not the first time we have seen such an event and, indeed, we did not see any transmission into the community. The behaviour of the virus has not changed, based on the epidemiological evidence from this event, and we remain at Pandemic Phase 3."
The WHO assesses the influenza pandemic threat according to a six level system. Phase 3 - which the world has been in since 2003 - involves no or limited human-to-human spread of a novel flu virus that has the theoretical potential to cause a pandemic.
In the Pakistan cluster, the initial case fell ill around Oct. 29 after having direct contact with infected poultry. The man recovered. But while he was ill he was cared for by two of his brothers, neither of whom had any known contact with infected birds.
The first of those brothers died on Nov. 19. While he is considered a probable case, he was never tested and cannot be added to the case count.
The second brother died on Nov. 28. It was his death that prompted health officials to consider H5N1 as a possible cause of the cluster of illnesses. A specimen taken from him before his death tested positive for the virus late last year.
Authorities then cast a broad net looking for other possible cases, identifying five members of the family, three unrelated poultry cullers and a doctor who cared for the family members as potentially being infected.
Of those, only the first or index case and one additional brother - who likewise had no known contact with sick poultry - have tested positive.
The event sparked a health investigation in the United States as well. Another brother from the family, who lives in Long Island, N.Y., had travelled to the funerals of the men who died.
On his return to the U.S. he informed health authorities of his exposure to possible H5N1 cases. The U.S. Centers for Disease Control in Atlanta sent a plane to collect specimens from the man for testing, but all tests came back negative.
With these newly confirmed cases, the count of known H5N1 cases since late 2003 rises to 378 in 14 countries. Of those, 238 people have died.

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http://canadianpress.google.com/article/ALeqM5hdRCUcGhj2ak4ywZGujoEVEKFxXg

**HenryN** · April 3, 2008, 11:56 AM

Re: WHO Update on Pakistan Cluster from November/December '07

Limited bird flu spread among Pakistan brothers-WHO

Thu 3 Apr 2008, 15:25 GMT
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By Stephanie Nebehay
GENEVA, April 3 (Reuters) - At least three brothers in Pakistan were infected with the bird flu virus last year, and some human-to-human spread likely occurred, the World Health Organisation (WHO) said on Thursday.
But the United Nations agency said the deadly disease had not gone beyond the family cluster near Peshawar, suggesting "limited human to human transmission".
"This outbreak did not extend into the community and appropriate steps were taken to reduce future risks of human infections," it said in a statement.
Similar clusters of H5N1 bird flu virus within families have been previously detected in Indonesia, Thailand and Vietnam.
The WHO had earlier confirmed only one human H5N1 infection in Pakistan -- a 25-year-old man who died in late November. On Thursday, it said international laboratory tests have now confirmed that two of that man's brothers also had the disease.
One of those two brothers -- who both fully recovered -- was a veterinarian involved in culling infected poultry, whose symptoms began in late October, making him the first or "index case" of the bird flu cluster.
None of the veterinarian's brothers had any direct contact with sick or dead poultry, according to the WHO.
But it said a fourth brother, who also died in mid-November after having close contact with the sick veterinarian, was considered a "probable" case. No blood or tissue samples had been taken from his body, so it never could be proven.
The laboratory test results supported the findings of an investigation of the outbreak that "suggested limited human to human transmission likely occurred among some of the family members which is consistent with some human to human transmission events reported previously," the WHO said.
The largest known cluster of human bird flu cases occurred in May 2006 in the Karo district of Indonesia's North Sumatra province, where as many as 7 people in an extended family died.
Experts fear that the virus -- which has killed 238 of the 378 people known to have been infected with it since 2003 -- could mutate into a form that spreads easily from one person to another. That could trigger a deadly influenza pandemic.
All known close contacts of the Pakistani brothers, including other family members and health care workers, had been monitored and cleared for any signs of infection, according to the WHO. (Editing by Laura MacInnis)

reuters.com

http://africa.reuters.com/commodities/news/usnL03513766.html

**Laidback Al** · April 3, 2008, 01:31 PM

Re: WHO Update on Pakistan Cluster from November/December '07

I think these are the names of the brothers associated with the case numbers:

Ishtiaq Durrani (Case 1)
Mohammad Ilyas Durrani (Case 2)
Mohammad Owais (Idrees?) Durrani (Case 3)
Tariq Durrani (Case 4?)

Pakistan - BF Suspected Human Cases December 18, 2007 to Feb 2, 2008 - FluTrackers News and Information

http://www.flutrackers.com/forum/showpost.php?p=117075&postcount=8

**AlaskaDenise** · April 3, 2008, 01:59 PM

Re: WHO Update on Pakistan Cluster from November/December '07

Originally posted by niman View Post

Commentary at

http://www.recombinomics.com/News/04..._Pakistan.html

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</TD><TD style="VERTICAL-ALIGN: top; WIDTH: 515px" colSpan=5><BIG><BIG>Commentary </BIG></BIG>

Confirmed H2H2H H5N1 Transmission in Pakistan
Recombinomics Commentary 17:14
April 3, 2008

The recently released WHO update on the H5N1 transmission in Pakistan in late 2007 was human to human to (H2H2H). The transmission chain is supported by disease onset dates, contacts, and laboratory confirmation of three of the four members in the transmission. This chain would match the largest confirmed chain, which involved more family members, but was limited to two distinct transmission events in Karo, Indonesia.

For the Pakistan cluster, the index case was a veterinarian, who was infected while leading a cull of poultry in October, 2007. He developed symptoms on October 29, several days after the cull. He infected one of his brothers who cared for him. The brother developed symptoms on November 12 and died November 19. This brother infected two other brothers, who both developed symptoms November 21. One brother died November 27, while the other brother recovered.

Thus, of the four cases, two died and two recovered. Of these four, three were laboratory confirmed, but only one of the three (the second dead brother) was confirmed with PCR and virus isolation. The other two were confirmed serologically. The first brother to die was not laboratory confirmed and therefore is officially a probable case, based on clinical course, including pneumonia and death.

The latest update should clear up some of the confusion generated by the delays in reporting, false negatives linked to sample degradation, and conflicting and/or confusing statements, due in part to the delays (first media reports were in early January) and degradation.

This cluster also highlights weaknesses in testing. If this was not a cluster, it is likely that only one of the four cases would be confirmed instead of three of four. The three create a cluster, although the link between the index case and two brothers developing symptoms is the first fatality, who was not lab confirmed.

The identification of serious testing shortfalls through cluster analysis is not unusual. Most clusters have one or more aspects which involve false negatives or lack of sample collection / testing.

There are two such recent examples in Indonesia. In both clusters, no sample was collected from the index case, who died, and both clusters have H5N1 confirmed family members. One cluster was specifically denied and the denial was accepted at face value in a Promed commentary. The second index case has not been identified in the English language media. Neither suspect cluster was mentioned in the WHO update on Indonesia.

These failures to confirm obvious H2H in current clusters remains a cause for concern. Similarly, the confirmed H2H2H cluster in Pakistan raises additional questions about failures to report or confirm additional human H5N1 cases in Pakistan, India, and Bangladesh.
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**Giuseppe** · April 4, 2008, 02:05 AM

Re: WHO Update on Pakistan Cluster from November/December '07

[From ProMed moderator CP]
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[This is the final instalment of the rather tortuous and conflicting story laid out in the ProMED-mail posts listed below, which is best forgotten.

The final analysis summarized in the table above now indicates clearly that person-to-person transmission of avian influenza virus infection occurred within a family of brothers in Peshawar, Pakistan.

There were, however, no further human-to-human transmission events and no spread of infection into the general community.

The interactive HealthMap at http://healthmap.org/promed?v=30,69.4,5 can be used to locate Peshawar, the capital of the North West Frontier province of Pakistan. - Mod.CP]
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**HenryN** · April 4, 2008, 03:11 AM

Re: WHO Update on Pakistan Cluster from November/December '07

Originally posted by ironorehopper View Post

[From ProMed moderator CP]
-
[This is the final instalment of the rather tortuous and conflicting story laid out in the ProMED-mail posts listed below, which is best forgotten.

The final analysis summarized in the table above now indicates clearly that person-to-person transmission of avian influenza virus infection occurred within a family of brothers in Peshawar, Pakistan.

There were, however, no further human-to-human transmission events and no spread of infection into the general community.

The interactive HealthMap at http://healthmap.org/promed?v=30,69.4,5 can be used to locate Peshawar, the capital of the North West Frontier province of Pakistan. - Mod.CP]
-

Login Page

http://apex.oracle.com/pls/otn/f?p=2400:1001:3812790993135286::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,72077

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It is worth remembering that this same commentator has accept the denial of Indonesia that the current cluster involving a dengue fever diagnosis in West Java, while the brother died of H5N1 (and was initially also diagnosed as dengue fever). Moreover, as seen in the the Pakistan cluster, symptoms developed within a few days of the death of the earlier case (which is common in H5N1 H2H clusters).

**HenryN** · April 4, 2008, 04:28 AM

Re: WHO Update on Pakistan Cluster from November/December '07

Originally posted by ironorehopper View Post

[From ProMed moderator CP]
-
[This is the final instalment of the rather tortuous and conflicting story laid out in the ProMED-mail posts listed below, which is best forgotten.

The final analysis summarized in the table above now indicates clearly that person-to-person transmission of avian influenza virus infection occurred within a family of brothers in Peshawar, Pakistan.

There were, however, no further human-to-human transmission events and no spread of infection into the general community.

The interactive HealthMap at http://healthmap.org/promed?v=30,69.4,5 can be used to locate Peshawar, the capital of the North West Frontier province of Pakistan. - Mod.CP]
-

Login Page

http://apex.oracle.com/pls/otn/f?p=2400:1001:3812790993135286::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,72077

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Here are links to the posts. It is worthwhile counting the number of times CP stated that the cluster in Pakistan was NOT H2H

[see also:
Avian influenza, human (05): China, Pakistan 20080110.0134
Avian influenza, human (03): Egypt, Pakistan, WHO 20080104.0038
2007
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Avian influenza, human (177): Pakistan, Viet Nam, Egypt 20071227.4152
Avian influenza, human (172): China, Pakistan 20071222.4110
Avian influenza, human (171): Pakistan 20071220.4089
Avian influenza, human (169): Pakistan 20071218.4072
Avian influenza, human (168): Pakistan 20071217.4059
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/msp/sh

**sharon sanders** · April 4, 2008, 06:58 AM

Re: WHO Update on Pakistan Cluster from November/December '07

Test reports confirm brothers died of bird flu

<center> By Ashfaq Yusufzai</center>
PESHAWAR, April 3: The World Health Organisation (WHO) has confirmed two cases of human-to-human transmission of avian influenza in Pakistan.

According to WHO, a resident of Tajabad, who died of H5N1 avian influenza, had already been confirmed had contracted the infection from his brother, a poultry worker, in November.

Officials said that two samples collected from a family in Peshawar tested positive for avian influenza in serological test done in a WHO H5 reference laboratory in Cairo and at the Collaborating Centre for Reference and Research on Influenza in Atlanta.

The test report said that a poultry worker in the same family transmitted the H5N1 strain virus from poultry farm to home due to which his 28-year-old brother died with symptoms of bird flu on Nov 19.

He was not tested for bird flu, but WHO officials said that the symptoms showed that he probably died of it.

On Nov 28, his younger brother died of bird flu.

The same day, the global health agency?s headquarters in Geneva announced that a case of human-to-human virus transmission had occurred in Pakistan.

?Today (Thursday), it was confirmed that two more brothers of the two deceased had developed bird flu.

?They have fully recovered now,? the officials said.

The laboratory test results support the epidemiological findings from the investigation in Dec 2007, and the final risk assessment suggested that limited human-to-human transmission likely occurred among some of the family members, which are consistent with events reported previously.

The disease did not spread into the community and appropriate steps were taken to reduce future risks of human infections, the officials said.

In view of the confirmation of H5N1 strain of the infection, the government is dragging its feet on the implementation of the PC-1 aiming to set up two respiratory isolation units for suspected patients of bird flu.

In addition, the world health agency agreed to set up two wards each at the KTH and Ayub Teaching Hospital in Abbottabad at an estimated cost of 500,000 dollars, but no progress is in sight so far.

Test reports confirm brothers died of bird flu

http://www.dawn.com/2008/04/04/nat21.htm

PESHAWAR, April 3: The World Health Organisation (WHO) has confirmed two cases of human-to-human transmission of...

**Anne** · April 4, 2008, 07:54 AM

Re: WHO Update on Pakistan Cluster from November/December '07

I don't understand this :

Two more H5N1 cases from Pakistan cluster verified

http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/apr0308pakistan.html

Serologic tests were used to confirm the two latest cases because no respiratory samples were available, Hartl confirmed today. Explaining why the results were delayed, he told CIDRAP News via e-mail, "Serology takes awhile because the virus has to be grown in sufficient quantity to perform [the] test with sera."
Hartl said the virus in the third Pakistani patient was identified as a clade 2.2 strain of H5N1. Clade 2.2 viruses have been found in birds in more than 60 countries in Asia, Europe, the Middle East, and Africa, and have caused human cases in Azerbaijan, China, Egypt, Djibouti, Iraq, Nigeria, and Turkey, as well as Pakistan, according to a recent WHO report.
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wich virus didn't grown ? the virus from pakistan ?
it could be possible to make serologicals tests without the "exact" virus, I think.