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**Gert van der Hoek** · January 3, 2012, 10:39 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Vincent Racaniello has a point: we don't know the CFR of H5N1.

I remember a statement from dr Nidom, Indonesia, saying he expected a very high percentage (50% +) of inhabitants of Jakarta would show H5N1-antibodies.

Should we fear avian H5N1 influenza?

3 JANUARY 2012

Why is there such widespread fear of avian H5N1 influenza virus?

In a recent study of rural Thai villagers, ..... , 73 participants (9.1%) had antibody titers against one of two different H5N1 strains.

Until we know how many individuals are infected with avian influenza H5N1, we must refrain from making dire conclusions about the pathogenicity of the virus.

Read more - Viroloy blog

Thailand - Evidence for Subclinical Avian Influenza Virus Infections Among Rural Villagers - 2008

**Vibrant62** · January 3, 2012, 02:28 PM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

H5N1 exists in many forms in its zoonotic host reservoirs of birds, whether wild birds or poultry. The sheer number of substrains that co-exist and circulate at the same time in different and the same parts of the world is, I think, unprecedented for a zoonotic influenza.

Every couple of years (example: Quinghai Lake) we get mass die offs amongst bird populations that have had prior exposures to earlier clades of virus.

Not only does H5N1 virus have the potential to rapidly become highly pathogenic even if it starts as a low path substrain, but there does not appear to be the same high levels of cross immunity to this virus generated by prior infection that are seen in all other influenza viruses.

The three families of virus with polybasic cleavage sites all have the potential to be highly pathogenic i.e H5, H7 and H9 viruses. Low path strains of all three of these 'viral families' have the potential to rapidly become high path with just a few additions to the length of the cleavage chain.

As evidenced by infections in birds, and even ducks (which are usually silent carrier hosts of influenza) these viruses can produce mass die offs in every species with relatively small changes in the H5 virus genetic make up, even in birds with pre-existing immunity.

There seems to be an assumption that an H5 human pandemic would generate/create cross immunity to future strains, and that it would become mitigated in severity after the initial outbreak. I do not wish to be unduly pessimistic, but I would suggest that the evidence before us (namely H5N1 behaviour and pathogenicity in birds) suggests otherwise. Vaccinated poultry have produced subclinical infections in many cases, but periodically, mass die offs occur with very high CFRs in these vaccinated birds. There is no scientific reason I can think of that would suggest that the experience in humans would be any different.

If we really think that an H5N1 human pandemic is a serious possiblity, we have to plan for, and develop, mitigation strategies for such an eventuality in humans i.e recurring high path outbreaks. We may not get them every year, but every couple of years is a distinct possibility for a very long time.

Some outbreaks may be 'mild' in nature with cross immunity provided by prior infection and vaccination, and some highly virulent outbreaks from new sub clades and clades should be expected as the virus and host reservoirs evolve and intermingle, just as we have seen occur in the avian host reservoirs.

Do not forget that we know from Indonesia and Egypt that H5N1 has shown itself to be quite adept at affecting multiple species including domesticated species e.g cats, dogs and pigs (that we know of), all of which provides the potential for rapid evolution of any humanised virus.

At present all planning considers only the primary outbreak. In my personal opinion, when considering where scarce resources should be directed for research and development of mitigation therapies and strategies, we need to be thinking beyond the initial 1 - 3 years, much like we have for AIDS. We need to be thinking beyond the initial outbreak to the evolution of a likely time where antiviral resistance is 100%

It is not all doom and gloom though.

The solution to this would be the successful completion of development of a universal vaccine; science is close to achieving this. Only when we have such a vaccine in hand, and the capacity to vaccinate every man, woman and child and every domestic animal that is suscesptible, globally, can we seriously plan an end to the threat that this virus poses to the world in the longer term.

**Laidback Al** · January 3, 2012, 03:57 PM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Originally posted by Vibrant62 View Post

At present all planning considers only the primary outbreak. In my personal opinion, when considering where scarce resources should be directed for research and development of mitigation therapies and strategies, we need to be thinking beyond the initial 1 - 3 years, much like we have for AIDS. We need to be thinking beyond the initial outbreak to the evolution of a likely time where antiviral resistance is 100%

Excellent point - Except the scary issue is that antiviral resistance may lead to an H5N1 pandemic.

We know that oseltamivir is the only effective antiviral treatment for H5N1. Currently, the regime for oseltamivir in Indonesia is a double dose for five days. It has to be started with 48 hours of showing symptoms and even then the patient does not always survive.

We do know from media reports that Indonesia has a policy of prophylactically administering oseltamivir to all contacts of suspected bird flu cases. So far this strategy has been successful, H5N1 has not spread beyond the initial case or cluster in Indonesia. Although not publicized, Egypt and China most likely have the same policies of administering antivirals as a prophylaxis for H5N1.

But the potential exists for an oseltamivir resistant strain of H5N1 to develop in one of these clusters of antiviral recipients and escape. In that case, the local public health officials would no longer be able to contain the outbreak. Depending on the transmissibility of the strain, it could become a local epidemic with a short jump around the world to a full blown pandemic from an antiviral resistant strain.

**alert** · January 3, 2012, 05:31 PM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Originally posted by Gert van der Hoek View Post

Vincent Racaniello has a point: we don't know the CFR of H5N1.

I remember a statement from dr Nidom, Indonesia, saying he expected a very high percentage (50% +) of inhabitants of Jakarta would show H5N1-antibodies.

Should we fear avian H5N1 influenza?

3 JANUARY 2012

Read more - Viroloy blog

Thailand - Evidence for Subclinical Avian Influenza Virus Infections Among Rural Villagers - 2008

Unfortunately, the existence of clusters of fatalities, such as the Ginting family in Indonesia, argues for a higher CFR. Keep in mind, by comparison, infection of perhaps a third of the world population with H1N1 in 2009 only produced a handful of instances of two linked deaths, and no instances of three. We are already aware of more and larger H5N1 death clusters than of H1N1 ones, suggesting that the CFR of H5N1 is significantly higher than that of H1N1.

**Laidback Al** · January 10, 2012, 01:54 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Could a Potential H5N1 Pandemic Start in a Metropolitan Area?

Little by little, the information from the 2009 H5N1 cases in Indonesia is starting to be filled in by media reports. In 2009, Indonesia balked at complying with IHR regulation regarding the immediate reporting of H5N1 cases. On December 28, 2009, Indonesia reported 20 human cases of H5N1 throughout 2009 (link). Little was known about these 20 cases at the end of 2009.

In September 2011, a 2009 human cluster of three individuals from Jakarta was finally reported in the media (link). The recent media report from vivanews discussing the latest suspected H5N1 case in Jakarta states ?According to the Jakarta Health Service data, during 2009, of 10 patients suspect bird flu, 8 patients had died (84 percent). In 2010 the number decreased to 3 patients, but all three died (100 percent). Then in 2011 from three patients, two people died.? (FT link) {Menurut data Dinas Kesehatan DKI, selama 2009, dari 10 pasien suspect flu burung, 8 pasien meninggal dunia (84 persen). Pada 2010 jumlahnya menurun menjadi 3 pasien, namun ketiganya meninggal dunia (100 persen). Kemudian pada 2011 dari tiga pasien, dua orang meninggal.} (original link)

This media report suggests that half (10 of 20) of the H5N1 cases in 2009 in Indonesia occurred in the greater metropolitan Jakarta area. In light of the recent H5N1 case from north Jakarta, Puguh Dwi Yanto (24M), who died on Jan 7, 2012 and has yet to be announced by WHO, we should be concerned that a potential H5N1 pandemic could just as easily start in a large urban center like Jakarta rather than a countryside village.

**JJackson** · January 11, 2012, 11:36 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

For a pandemic of Zoonotic origin there are two distinct phases.
First you need the animal to human contact.
Second you need human to human contact.
At stage two you have a basically non human disease attempting to spread among humans. Its Ro is likely to be low and it needs lots of contacts (of what ever transmission system it employs) to perfect its infection skills, and so up its Ro. Densely packed humanity is obviously the best place for it to go from zoonotic infection to human pandemic.
The ideal for stages one and two (in avian flu's case) is a city where the population have lots of contact with birds, preferably ducks as they can be infectious and apparently healthy.
Rice growing areas are a problem as ducks are a secondary crop as they keep down pests in the paddy and then become entrenched in the local culture and cuisine so even when these population become city dwellers they retain the duck keeping, and eating, tradition.

**Shannon Bennett** · January 11, 2012, 12:49 PM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

I believe the reason there have been so few urban cases of H5N1 is due to the vectors rather than herd immunity. In very large cities few people have a flock of chickens or ducks. The only exception to this are large 'wet markets' where poultry from outlying regions is brought into the city for slaughter. The reason so many were worried when the latest Hong Kong resident died of H5N1 infection was he had no contact with either wild or domestic birds. When we start to see cases in urban areas we need to pay attention.

As for the CFR. Novel influenza almost always results in an uptick of fatalities. Sometimes to a high degree as was the case in 1918. The first varients found at Ft. Riley during the summer were serious but, no where close to the severity of the fall varients. We know from the now censored ferret study last fall that H5N1, in ferrets at least, was terrifying. If the disease as it exits in humans today doesn't change radically when it makes the leap to H2H, we are in serious trouble. The only reason the CFR has remained at apprx. 60% to date is because of immediate use of a single antiviral. What happens when this drug no longer works? What happens when we run out of vents? What happens when most of the hospital workers are stricken with the disease. Changes to the virus is what most seem to be hoping for but how realistic is this? There have been pandemics throught our history why would now be any different?

**Laidback Al** · January 18, 2012, 11:17 PM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Avian Influenza in Wild Birds in Vietnam

In Avian influenza viruses in wild land birds in northern Vietnam, the authors research H5 antibodies in wild birds in Vietnam. In 2007, four of 197 samples were positive, about 2%. In 2008, 14 of the 193 collected samples were apparently positive, almost double the rate of the year before (about 7%). Of significance is that less than half of the genera reported in the article have been identified as affected by avian influenza See: USGS - List of Species Affected by H5N1 (Avian Influenza)

The authors provide this recommendation. ?Our results suggest that attention should be given to terrestrial species, particularly flocking passerines, in AIV surveillance and monitoring programs.?

**Laidback Al** · January 21, 2012, 08:08 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Preparing for the Next Pandemic

An article by Fleming And Durnall just published in Human Vaccines & Immunotherapeutics presents 10 observations and practical suggestions that need to be considered before the start of the next pandemic. Unfortunately, as important as these points are, they will probably not receive widespread attention or be taken seriously, at least not until the start of the next pandemic.

Ten lessons for the next influenza pandemic?an English perspective: A personal reflection based on community surveillance data

Volume 8, Issue 1 January 2012

Douglas M. Fleming and Hayley Durnall

Douglas M. Fleming
Corresponding author: dfleming@rcgpbhamresunit.nhs.uk
Department of Virology, Erasmus MC; Rotterdam, the Netherlands

Hayley Durnall
Royal College of General Practitioners; Research and Surveillance Centre; Birmingham, UK

We review experience in England of the swine flu pandemic between May 2009 and April 2010. The surveillance data from the Royal College of General Practitioners Weekly Returns Service and the linked virological data collected in the integrated program with the Health Protection Agency are used as a reference frame to consider issues emerging during the pandemic. Nine lessons are summarized.

(1) Delay between illness onset in the first worldwide cases and virological diagnosis restricted opportunities for containment by regional prophylaxis.

(2) Pandemic vaccines are unlikely to be available for effective prevention during the first wave of the pandemic.

(3) Open, realistic and continuing communication with the public is important.

(4) Surveillance programs should be continued through summer as well as winter.

(5) Severity of illness should be incorporated in pandemic definition.

(6) The reliability of diagnostic tests as used in routine clinical practice calls for further investigation.

(7) Evidence from serological studies is not consistent with evidence based on health care requests made by sick persons and is thus of limited value in cost effectiveness studies.

(8) Pregnancy was an important risk factor.

(9) New strategies for administering vaccines need to be explored.

(10) Acceptance by the public and by health professionals of influenza vaccination as the major plank on which the impact of influenza is controlled has still not been achieved.

http://www.landesbioscience.com/jour...article/18808/ (hat tip to Tetano for the abstract link.)

Comment

The irony is that the senior author?s affiliation is with the Department of Virology at the Erasmus Medical Center, the same department that has conducted H5N1 research under the direction of R. A. Fouchier (FT Link). If as much media attention was directed at preparing for the next pandemic as has been directed at Fouchier?s research, the world might be better prepared for the next pandemic whether it is H5N1 or some other emerging infectious disease.

**Laidback Al** · February 6, 2012, 10:47 PM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

The H5N1 Research Publication Controversy

The debate continues to rage over whether or not the details of the laboratory-created virulent strain of H5N1 should be published (see this FluTrackers link for a full discussion). The heated exchange among the researchers raises many critical issues about scientific research and the protection of the public good.

But in my estimation this debate is a distraction from the real issue at hand - How can the world quickly and efficiently prepare for the next pandemic?

And there will be a next pandemic.

Governments and public health organizations need to focus on new production and delivery strategies for vaccine and encourage researchers to develop new drugs to replace neuraminidase inhibitors for when they are no longer effective. The 2009 H1N1 pandemic demonstrated how ill-prepared the world is to handle a pandemic. Lucky for us it was mild. We may not be so lucky if H5N1 goes pandemic.

Throughout history, humans have always taken the most recent scientific advances and turned then into weapons of death and destruction, starting with the invention of gun powder for fireworks in China in 9th century and continuing through the nuclear age in the 20th century with atomic bombs. Even today the world is wrestling with the issue of peaceful nuclear development versus atomic aggression. So the restriction of publication of the H5N1 research may delay, but will certainly not deter, the spread of the details to anyone determined to obtain them.

And the restriction of the data will not stop the next pandemic from occurring.

Once the next pandemic starts, it will not be important if it is a result a bioterrorist plot, a laboratory escape, or a virus born in the wild. What will be important is if the world is prepared for it.

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mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman","serif";} </style> <![endif]--> Let?s shift the focus of this debate from withholding research data to emphasizing the need for worldwide preparation for the next pandemic.

**Laidback Al** · February 14, 2012, 12:08 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Vietnam H5N1 poultry infections

Between 2003 and 2007 Vietnam had the world?s largest number of human cases of H5N1, a total of 93. In 2007 Indonesia finally exceed the total from Vietnam with 117 cumulative H5N1 human cases. Within the past few weeks Vietnam has experienced several outbreaks of H5N1 in poultry and reported two human deaths from H5N1.

See these FT links:

Highly pathogenic avian influenza, Vietnam (OIE, February 13 2012): 4 New H5N1 Poultry Outbreaks

Highly pathogenic avian influenza, Vietnam (OIE, February 13 2012): 2 New H5N1 Poultry Outbreaks, Ha Nam, Hai Duong

Highly pathogenic avian influenza, Vietnam (OIE, February 10 2012): 2 New H5N1 Poultry Outbreaks, Hai Duong, Ha Nam

Highly pathogenic avian influenza, Vietnam (OIE, February 8 2012): 3 New H5N1 Poultry Outbreaks, Quang Tri, Thanh Hoa

Highly pathogenic avian influenza, Vietnam (OIE, February 6 2012): 1 New H5N1 Poultry Outbreak, Soc Trang

Vietnam: Smuggled poultry trade despite the influenza A/H5N1 virus

Vietnam - Woman, 26, died of H5N1 bird flu says MOH - Soc Trang province

Vietnam - Man, 18, tests positive for bird flu H5N1 (WHO confirmed)- dies - Kien Giang Province

Because the most likely scenario for the start of an H5N1 pandemic will involve an individual who contracts the disease from sick poultry, two local reporters from Viet Nam News posed a series of questions about H5N1 and poultry infections to several local experts. Excerpts are presented below. Read the full interview at: http://vietnamnews.vnagency.com.vn/o...us-threat.html

What is the main reason for the resurgence of bird flu at this moment?

Dr. Santanu K. Bandyopadhyay, Team Leader Avian Influenza Programme, Food and Agriculture Organisation of the United Nations (FAO) in Viet Nam: In northern Viet Nam and parts of central Viet Nam, we have seen the emergence of a new strain of the bird flu virus since the beginning of 2011. This particular virus is not adequately protected by the currently available vaccines for poultry. Due to the complexity of this virus strain, the government has halted the mass vaccination of poultry since the summer of last year. So there is now a large number of vulnerable poultry populations not immune to the disease. Therefore, a disease outbreak in such a naive population will spread fast and involve huge losses to the poultry. . .

Ph.D Nguyen Van Cam, deputy director of the Ministry of Agriculture and Rural Development's Centre for Veterinary Public Health: The resurgence of this disease is the result of unfavourable weather conditions weakening the resistance of poultry and the poultry production system of small-farm oriented and free-grazing ducks failing to adopt appropriate bio-security measures. We have to get used to living with this disease.

It is not right to assume that stopping mass vaccination nationwide is the main cause of the disease's outbreak. . . No country has sustained a mass vaccination programme in poultry for a long time. After an emergency situation has been controlled with vaccinations, a strategic exit-plan has to be applied in which vaccinations are gradually withdrawn.

Dr. Graham Harrison, Acting WHO Representative: Viet Nam is considered to be endemically infected with H5N1 . . . H5N1 viruses will likely continue to persist and be a concern for Viet Nam and more widely, pose a threat to the poultry industries and remain a potential source of pandemic human influenza. . . .

Prof. Nguyen Tran Hien, Director of the National Institute of Hygiene and Epidemiology:The Ministry of Agriculture and Rural Development reports that 5 per cent of ducks were infected with H5N1 virus. . . .There is a high risk of H5N1 virus transmission from animals to humans. The biggest problem is that many people have not been fully aware about the risk of disease after a long time of no infected cases in humans. . . . In the coming time, we forecast that bird flu in poultry could break out in many provinces and bird flu in humans will also occur scatteredly.

Is it farmers that should be blamed for the spread of the disease?

Cam: No, it's not their fault for the spread of bird flu. If we wish to raise their awareness of the disease in a timely way, we should first publish and implement the supporting policies to assist them in case their poultry is contaminated. . . .So when farmers find that they may lose their flocks of poultry, their most precious assets, they will have to find a way to lessen their losses by selling them off.

Bandyopadhyay: We cannot entirely blame them when they don't want to bring signs of any sickness in their poultry to the attention of the authorities. It is necessary for the Government to give a supporting hand to them when trying to encourage them to promptly report any signs of infection.

Which short and long-term measures should Viet Nam take to cope with this disease?

Harrison: Control measures must continue to focus on reducing the transmission of the virus ? both to other poultry and to people. Key transmission pathways for this virus are bird to bird, farm to farm, or market to farm. Also spreading happens through contaminated materials and equipment such as manure, feathers, vehicles and soiled clothing. In order to reduce the threat of H5N1 infections, transmission pathways of the infection will have to be broken. . . .

Bandyopadhyay: . . .In the long-term, both the disease management and the poultry production management need to be improved.

There is a need for investments in improving the veterinary service delivery system, particularly in the rural areas so that the poultry farmers are adequately advised on appropriate care, vaccination and bio-security methods in farms. Investments will be required in surveillance for the disease rather than waiting for these to be brought to the notice of the authorities. The farmers have to be encouraged to report any sickness in their flock rather than try to sell off or eat sick birds themselves.
. . .

Cam: Viet Nam has yet to be successful in producing its own vaccine because H5N1 virus continuously evolves through mutation and re-assortments. It forms its new strains during the process of researching, experimenting and creating a vaccine, which in Viet Nam takes several years. So, I put forward two long-term solutions.

First, the country needs to build a system of local animal health workers who take responsibility for detecting and reporting signs of sickness in poultry to the higher authorities to immediately respond. . . .

Second, appropriate bio-security measures should be applied to poultry production in the country.

What should people do to protect themselves?

Hien: Both of the two fatal cases resulted from too late hospitalisation and treatment. So, it is important to early detect and treat patients. People are absolutely not allowed to slaughter and eat ill poultry. Personal hygiene and food safety measures should also be followed. People, who have a high fever and are in proximity to sick poultry need to come to the medical unit for examination and treatment.

Harrison: It is very important that the general public always take simple precautions to reduce exposure to the H5N1 virus. These include extra vigilance in cases of sudden disease and death in poultry, immediate reporting of the disease to authorities and good hygiene practices while handling, slaughtering and preparing poultry for consumption. ? VNS

http://vietnamnews.vnagency.com.vn/o...us-threat.html

Shiloh

**Laidback Al** · February 14, 2012, 12:35 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Are New Strains of H5N1 Evolving in Indonesia?

From this post by Shiloh - Indonesia: H5N1 symptoms in poultry have changed

Chairman of the Avian Influenza Research Center, zoonosis, which is also a lecturer at the Faculty of Veterinary Medicine Airlangga University, Surabaya, CA Nidom, say, the existence of the bird flu virus in Indonesia to worry about. "There are allegations of meetings between the H5N1 virus (bird flu) and pan2009 A H1N1 (swine flu) in Indonesia. This could produce a new type of virus is more dangerous, "he said.

Allegations were based on the character of the virus that continues to change with the environmental conditions are in place. During research in the laboratory, he saw that the bird flu virus is very sensitive. When the electricity in the laboratory die, for example, the character of the virus is changing to respond to environmental changes.

Comment - As one of the foremost bird flu researchers at Airlangga University in Surabaya, CA Nidom should know what he is talking about. His comments suggest that he may have observed the same kind of viral changes in his lab that has been causing so much controversy in the media about laboratory created strains of virulent H5N1 in Wisconsin and the Netherlands. (see: this FluTrackers thread)

**Gert van der Hoek** · February 14, 2012, 05:53 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Originally posted by Laidback Al View Post

Are New Strains of H5N1 Evolving in Indonesia?

From this post by Shiloh - Indonesia: H5N1 symptoms in poultry have changed

Comment - As one of the foremost bird flu researchers at Airlangga University in Surabaya, CA Nidom should know what he is talking about. His comments suggest that he may have observed the same kind of viral changes in his lab that has been causing so much controversy in the media about laboratory created strains of virulent H5N1 in Wisconsin and the Netherlands. (see: this FluTrackers thread)

If I look at the Toggletext translation it could be less dramatic.

It seems Nidom is talking about the possibility of "a meeting" between H5N1 and the novel H1N1. This is a real possibility, like it is in other countries where H5N1 is endemic.

For me it is to soon to conclude this "meeting" was observed already in the wild.

Similar H5N1 mutations as shown in the Kawaoka/Fouchier researches? I don't see any proof of that?

The point in the Kompas article seems to be the observation that poultry is showing less symptoms?

This observation and the possible reassortment of nH1N1 and H5N1 both are worrying enough.

Avian Influenza-zoonosis Research Center Chairman, that also the lecturer in the Universitas Airlangga School Of Veterinary Medicine, Surabaya, CA Nidom, said, the existence of the bird flu virus ought to be in Indonesia worried.

"There was the assumption" of the "meeting between the virus H5N1 (bird flu) and A H1N1 pan2009 (pig flu) in Indonesia."

This could produce the more dangerous new virus kind, he said.

**Laidback Al** · February 28, 2012, 12:06 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Should The World Be Concerned About Suspected Human H5N1 Clusters in Gowa Regency, South Sulawesi, Indonesia?

Since late December there have been three media-reported clusters of suspected human H5N1 cases in Gowa Regency in Indonesia, each associated with a confirmed H5N1 poultry outbreak.

Cluster 1 ? Erelembang, Gowa Regency, December 20, 2011 to January 13, 2012 (link).

This suspected H5N1 cluster included three family members who died, four other symptomatic individuals who were isolated (including other family members), and at least 11 other individuals who received antiviral treatment. As I note in that thread, no official diagnoses were presented by public health officials regarding the deaths or hospitalizations.

Cluster 2 - Panaikang, Pallangga District, Gowa Regency, February 18(?), 2012 to February 27, 2012 (link).

Five family members, including three children, were suspected with H5N1 infections and were taken to the bird flu Hospital in Makassar for treatment. The youngest, a three month-old baby, was apparently treated in isolation. Today, just as the media reports emerged about a third human cluster of suspected H5N1 cases in Gowa Regency, the media reported that all five of these individuals tested negative for H5N1.

Cluster 3 ? Parang Banoa, Pallangga District, Gowa Regency, February 26, 2012 to ?? (link).

On February 26, one individual from this village, Rusdi, was taken to the Makassar hospital with symptoms of H5N1 infection and was placed in intensive care. Hundreds of his chickens died suddenly. On February 28, between 10 and 20 other individuals from the same village complained of flu symptoms, but are reported to only be suffering from ?stomach upset?.

Discussion

So far, no deaths from suspected bird flu patients have been reported from Gowa Regency since the death of three siblings in late December and early January. As noted elsewhere in this and the previous thread (link), Indonesia only seems to officially confirm H5N1 cases that die. The standard treatment for a possible H5N1 infection in Indonesia is a double dose of oseltamivir. As long as antivirals are administered early enough, the infected patient will probably not die and will come up negative on H5N1 tests.

Taken together, since mid-December 2011, there have been a minimum of 34 individuals with suspected H5N1 infections in the Gowa Regency among three clusters, each cluster in an area with confirmed H5N1 poultry infections.

If a wild H5N1 virus is going to reassort into a transmissible pandemic influenza virus, then the Gowa Regency in South Sulawesi seems like a good location to monitor for such a novel H5N1 reassortment event.

**Laidback Al** · March 21, 2012, 11:56 AM

Re: How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2

Some potentially good news for children infected with H5N1 and intriguing research results. . . .

Clin Infect Dis. (2012) doi: 10.1093/cid/cis295 First published online: March 15, 2012

H5N1 Avian Influenza in Children

+ Author Affiliations

1Yuzuncu Yil University, Van, and
2Ataturk University Medical School, Erzurum, Turkey
3Azerbaijan Ministry of Health, Baku, Azerbaijan
4University of Indonesia, Depok, Indonesia
5London School of Hygiene and Tropical Medicine, and
6Royal Free and University College Medical School, Department of Infection and Immunity, Academic Centre for Travel Medicine and Vaccines, London, United Kingdom
7Faculty of Medicine, Chinese University of Hong Kong
8Princess Margaret Hospital, Hong Kong, SAR
9Ministry of Public Health, Nonthaburi, Thailand
10Khyber Teaching Hospital, Peshawar, Pakistan
11St Nicholas Hospital, Lagos, Nigeria
12Outcome Sciences, Inc, Cambridge, Massachusetts

Corresponding Author: Dr. Nancy A. Dreyer, Outcome Sciences, 201 Broadway, Cambridge, MA, 02139 (ndreyer@outcome.com)

Alternate Corresponding Author: Dr. Stephen Toovey, Royal Free and University College Medical School, Department of Infection and Immunity, Academic Centre for Travel Medicine and Vaccines, London, United Kingdom, (malaria@sunrise.ch)

A patient registry, representing the largest global knowledge base on clinical presentation and case fatality for confirmed cases of avian influenza, shows that most pediatric cases who present with rhinorrhea survive this infection, regardless of country and antiviral treatment.

Abstract

Background Avian influenza continues to pose a threat to humans and maintains the potential for greater transmissibility. Understanding the clinical presentation and prognosis in children will help guide effective diagnosis and treatment.

Methods A global patient registry was created to enable systematic collection of clinical, exposure, treatment and outcomes data on confirmed cases of H5N1. Bivariate and multivariate statistical tools were used to describe clinical presentation and evaluate factors prognostic of survival.

Results Data were available from 13 countries on 193 cases <18 years who were confirmed as having been infected with H5N1; 35.2% of cases were from Egypt. The case fatality rate (CFR) for children was 48.7%, with Egypt having very low pediatric CFR. Overall, children aged ≤5 years had the lowest CFR and were brought to hospital more quickly and treated sooner than older children. Pediatric cases who presented for medical care with a complaint of rhinorrhea had a 76% reduction in the likelihood of death compared with those who presented without rhinorrhea, even after statistical adjustment for age, having been infected in Egypt, and oseltamivir treatment (P=0.02). Delayed initiation of treatment with oseltamivir increases the likelihood of death, with an overall 75% increase in the adjusted odds ratio for death for each day of delay.

Conclusions The presence of rhinorrhea appears to indicate a better prognosis for children with H5N1, with most cases surviving regardless of age, country, or treatment. For cases treated with oseltamivir, early initiation of treatment substantially enhances the chance of survival.

Footnotes

Received November 8, 2011.
Revision received February 1, 2012.
Accepted February 23, 2012

From http://cid.oxfordjournals.org/conten...is295.abstract

Full text of accepted manuscript here: http://cid.oxfordjournals.org/conten....full.pdf+html

Important points from the article:

The clinical presentation of avian influenza in children differs in some meaningful ways from that in adults. Unlike some earlier reports that characterized H5N1 infections as carrying a higher mortality in children, the lower mortality rate in children aged <5 years in this large case series is quite striking, especially since the survival benefit is evident even when type of presenting symptom, antiviral treatment, time to treatment initiation and country are taken into account [8,9]. Of note, using a small
series from Vietnam (N=36), Kawachi et al reported that children aged 6years were at higher risk of fulminant disease with acute respiratory distress syndrome (ARDS) than younger children [10]. It might be that the less mature systems of younger children mount an immune response less harmful to their hosts.
. . .
The presence of rhinorrhea at presentation is more common in children aged <5 years, and appears to be associated with a markedly decreased risk of death in this age group. . . . Thus, there remains an intriguing difference in the frequency of rhinorrhea as a presenting symptom and its apparent prognostic value, which declines with increasing age. One might speculate that this represents primary inoculation of the virus into the upper rather than the lower airways, or perhaps a less injurious pathway to immune activation [11]. . . .

hat tip Tetano

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How Dangerous is Bird Flu (H5N1) to Global Public Health? Part 2 (Oct 17, 2011 - Nov 25, 2012)

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