Avian, human flu coinfection reported in Indonesian teen

[Gert van der Hoek]

Via Crofsblog:

Avian, human flu coinfection reported in Indonesian teen

Maryn McKenna Contributing Writer


Mar 17, 2008 – ATLANTA (CIDRAP News) – An Indonesian teenager has been brought forward as a case of simultaneous infection with seasonal and avian strains of influenza—a possibility that health planners have long warned could give rise to a pandemic flu strain.

In a paper presented today at the International Conference on Emerging Infectious Diseases, Vivi Setiawaty of Indonesia's Center for Biomedical and Pharmaceutical Research and Development described the case of a 16-year-old girl who was tested for flu in Jakarta in April 2007 under a flu-surveillance system established in 2005 by the Indonesian Ministry of Health.

The girl, who had been experiencing flu symptoms for several days, was only mildly ill, with a 100.5ºF fever, sore throat, cough, headache, and body aches, but no difficulty breathing and no signs of pneumonia. (Case reports of H5N1 patients in countries such as Thailand have described more dramatic clinical presentations.)

Throat and nasal-swab samples that were taken on the 6th day of her symptoms tested positive by reverse-transcriptase polymerase chain reaction (RT-PCR) for both avian influenza H5N1 and the seasonal flu strain H3N2 at the Indonesian National Institute of Health Research and Development. Serology test results were less clear. Antibody titers from serum samples taken the 6th day provided a weak indication of H5N1 infection (titer of 1:10) but were negative for H3N2; convalescent sera, on the other hand, gave a strong indication of H3N2 infection (titer of 1:640) but were negative for H5N1.

The test results were confirmed by the Eijkman Institute for Molecular Biology in Jakarta, an arm of the Indonesian Ministry of Research and Technology, according to the paper. The girl's case fell within the period when the Indonesian government was not sharing flu isolates with the international laboratory system maintained by the World Health Organization, and there was no indication whether her isolates were evaluated outside the country.

"This is the first case-report of a human with both influenza A/H5N1 and H3N2 co-infection," the paper states. "Such infections are of great concern due to the possibility of genetic reassortment leading to the emergence of a H5N1 strain that is more easily transmitted human to human, and emphasizes the importance of advanced laboratory-based surveillance in geographic regions where both human and avian influenza viruses are co-circulating."

http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/mar1708coinfect.html


Edit: this was posted before here: http://www.flutrackers.com/forum/showthread.php?p=141673#post141673

 

[Commonground]

Re: Avian, human flu coinfection reported in Indonesian teen

Throat and nasal-swab samples that were taken on the 6th day of her symptoms tested positive

This could be:
Rizky (14) Adm: 4/2 RSPI Sulianti Saroso, W. Java
Sym: 3/28. Recon: Carolus Hospital on 3/30.
Died: 4/5. Tested Positive.

 

[mixin]

Re: Avian, human flu coinfection reported in Indonesian teen

The girl, who had been experiencing flu symptoms for several days, was only mildly ill, with a 100.5?F fever, sore throat, cough, headache, and body aches, but no difficulty breathing and no signs of pneumonia.

It doesn't sound like this girl died.

 

[Commonground]

Re: Avian, human flu coinfection reported in Indonesian teen

It's the only "positive" I could come up with.

 

[Commonground]

Re: Avian, human flu coinfection reported in Indonesian teen

The girl's case fell within the period when the Indonesian government was not sharing flu isolates with the international laboratory system maintained by the World Health Organization, and there was no indication whether her isolates were evaluated outside the country.

You're right mixin, probably isn't her.

 

[mixin]

Re: Avian, human flu coinfection reported in Indonesian teen

She probably was overlooked when Indo wasn't reporting. I wonder how many others there were?

 

[Malcolm]

Re: Avian, human flu coinfection reported in Indonesian teen

http://www.flutrackers.com/forum/showthread.php?p=141673#post141673


SEE PRIOR POST 03-15-2008, 03:08 AM

Re: International Conference on Emerging Infectious Diseases 2008
PAGE 31
http://www.cdc.gov/eid/content/14/3/ICEID2008.pdf

Case Report: Dual Infection of H5N1 Avian Influenza and H3N2 Human Influenza in Jakarta

Indonesia, April 2007

V. Setiawaty; Center for Biomedical and Pharmaceutical R&D, Jakarta, INDONESIA.

Background: Human influenza A viruses are transmitted year round in Indonesia with a higher frequency
detected among patients with
influenza-like illness during the rainy season.


In 2005, the Ministry of Health established a referral system
for patients with avian Influenza A virus (H5N1) infection
and identified 113 patients with laboratory-confirmed disease
between 2005 and 2007.
We are reporting a case-report of a patient with simultaneous
infection with avian (H5N1) and human influenza A (H3N2)
virus infection.

Methods: In April 2007, a 16 year old female patient was hospitalized with respiratory
illness at a referral hospital in Jakarta. A case investigation form was used to collect clinical and
epidemiologic data and clinical samples were collected for hematological profile and as well as acute and
convalescent antibody titers for H1, H3, and H5 antigen using HAI assays. Throat & nasal swab
specimens were collected on the 6th day of onset, when she visited NIHRD laboratory and tested with
real-time and gel-based RT-PCR for H1, H3 and H5 at NIHRD-MOH. Patient was hospitalized after
results showed H5N1 positive infection. Specimens were sent to the Eijkman Institute for confirmation of
PCR results and genetic sequence analysis.

Results: The patient presented with moderate symptoms of
fever > 38?C, sore throat, cough, rhinitis, headache and myalgia, but no dyspnoea. The leucocytes counts
were 4,700-5,800 cells/mm3, lymphocyte 31 - 44.7%. no thrombocytopenia, X ray and CT scan of thorax
showed no pneumonia. PCR results were positive from throat and nasal swabs for influenza A/H3N2 and
H5N1 by real-time and gel based RT-PCR. These results were confirmed by repeat testing at Eijkman.
HAI antibody titers were negative for H3N2 and 1:10 for H5N1 from sera that was collected 6 days after
onset of illness. HAI antibody titers from convalescence sera were 1:640 for H3N2 and negative for
H5N1.

Conclusions: This is the first case-report of a human with both influenza A/H5N1 and H3N2 coinfection.
Such infections are of great concern due to the possibility of genetic reassortment leading to the
emergence of a H5N1 strain that is more easily transmitted human to human and emphasizes the
importance of advanced laboratory-based surveillance in geographic regions where both human and
avian influenza viruses are co-circulating.

 

[gsgs]

Re: Avian, human flu coinfection reported in Indonesian teen

don't forget, we had intrasubtype reassortment in Jan.2007
in the last public samples from Indonesia.

we don't know, whether the reassorted virus is still around there.
These were human samples, from avian samples we usually only have
(HA and NA) so further reassortments may be missed.

CDC had tested for reassortments of H5N1 and H3N2 in the lab.,
but no viable viruses were created.
I think, that was with the Vietnam/1203 virus.

 

[cartski]

Re: Avian, human flu coinfection reported in Indonesian teen

CDC had tested for reassortments of H5N1 and H3N2 in the lab.,
but no viable viruses were created.
I think, that was with the Vietnam/1203 virus.

I don't understand what "not viable" would mean - or rather, how come a reassortment would not work. I would have expected a new virus to be completed, with a new genetic makeup, but that the virus would have some resulting attributes that would not allow it to exist for very long in the real world.

What gives?

J.

 

[Giuseppe]

Re: Avian, human flu coinfection reported in Indonesian teen

You're right mixin, probably isn't her.

See post #85 in Ind. Human cases thread. (http://www.flutrackers.com/forum/showpost.php?p=142376&postcount=85)

It seems that the girl died.

 

[Commonground]

Re: Avian, human flu coinfection reported in Indonesian teen

Thanks ironorehopper. It may be her then. And this happened almost a year ago.....

 

[FluBossie]

Re: Avian, human flu coinfection reported in Indonesian teen

After reading this VERY late message from Indonesia about this case examination, I hope that every labworker/researcher in the world who possibly gets a possible bird flu patient will examine the throat and nasal-swab samples and serumsamples more thoroughly and should look out for reassortment and look for all influenza possibilities or combinations and will learn from this, because every expert in this field is expecting this evolvement and warns about.

Sorry to say it, but what a waist of time, but on the other hand better late than never. Hope Indonesia will be so friendly to send this sample to WHO.

Thanks for this thread Commonground, Ironhopper, Cartski, GSGS, Malcolm and Mixin.

 

[Laidback Al]

Re: Avian, human flu coinfection reported in Indonesian teen

The only 14-15 year old girl infected by H5N1 (to be later confirmed by WHO) during March and April of 2007 was Rizki Julianti from Pegangsaan, Jakarta Pusat.

http://www.who.int/csr/don/2007_05_16/en/index.html

 

[AlaskaDenise]

Re: Avian, human flu coinfection reported in Indonesian teen

Throat and nasal-swab samples that were taken on the 6th day of her symptoms tested positive by reverse-transcriptase polymerase chain reaction (RT-PCR) for both avian influenza H5N1 and the seasonal flu strain H3N2 at the Indonesian National Institute of Health Research and Development. Serology test results were less clear. Antibody titers from serum samples taken the 6th day provided a weak indication of H5N1 infection (titer of 1:10) but were negative for H3N2; convalescent sera, on the other hand, gave a strong indication of H3N2 infection (titer of 1:640) but were negative for H5N1.

Does the convalescent sera with a high titer for H3N2 indicates that it can overpower H5N1???

Since convalescent tests appear to be a reversal of the 6th day antibody titers, can we draw these conclusions or are other factors involved?

.

 

[gsgs]

Re: Avian, human flu coinfection reported in Indonesian teen

"convalescent sera" means : after 3 weeks ?
it takes 3 weeks for immunity to build up, I had read.
after 6 days it could have been too early for H3-titers
but H5N1 maybe started a bit earlier.
H5N1-infection is a bit slower than H3N2.

That gives the opportunity to use H3N2 as _therapy_
against H5N1 ??
reminds to our earlier "counterpandemic"-discussion, the idea
to produce immunity by deliberate infection
with a less virulent flu

 

[Giuseppe]

Re: Avian, human flu coinfection reported in Indonesian teen

"convalescent sera" means : after 3 weeks ?
it takes 3 weeks for immunity to build up, I had read.
after 6 days it could have been too early for H3-titers
but H5N1 maybe started a bit earlier.
H5N1-infection is a bit slower than H3N2.

That gives the opportunity to use H3N2 as _therapy_
against H5N1 ??
reminds to our earlier "counterpandemic"-discussion, the idea
to produce immunity by deliberate infection
with a less virulent flu

Even without a 'deliberate infection', with a seasonal human trivalent influenza vaccine (with adjuvant) it seems possible to exert a cross-reactive immune response: this may be useful if concurrently administer a poor-matched H5N1 vaccine in naive population.

In relation to Indonesian case, it is important to know exactly whether the patient died or not, and to have a clear picture of the clinical course, the anatomo-pathological finding (if died and post-mortem examination was conducted), in order to establish if H3 or H5 eventually killed the patient or not.

 

[gsgs]

Re: Avian, human flu coinfection reported in Indonesian teen

I thought, "convalescent sera" implied that she lived ?

looking up convalescent sera now...


---------------------------

what I found:

convalescent: recover from disease

acute serum is taken 1 week after onset
convalescent serum is taken 2-3 weeks (2-4 weeks, 1-2 months) after onset(?)

 

[HenryN]

Re: Avian, human flu coinfection reported in Indonesian teen

Even without a 'deliberate infection', with a seasonal human trivalent influenza vaccine (with adjuvant) it seems possible to exert a cross-reactive immune response: this may be useful if concurrently administer a poor-matched H5N1 vaccine in naive population.

In relation to Indonesian case, it is important to know exactly whether the patient died or not, and to have a clear picture of the clinical course, the anatomo-pathological finding (if died and post-mortem examination was conducted), in order to establish if H3 or H5 eventually killed the patient or not.

I don't see any evidenced that this was a fatal infection, and little evidence that it was anything more than seasonal flu. Its not an "official" WHO case, suggesting that a second PCR test was negative. There was no increase in titer and the initial titer of 10 is highly suspect becasue the titer was low and was negative in the convelescent serum.

This is just seasonal flu, with highly suspect H5N1 results that did not rise to teh level of an "official" case.

 

[HenryN]

Re: Avian, human flu coinfection reported in Indonesian teen

I don't understand what "not viable" would mean - or rather, how come a reassortment would not work. I would have expected a new virus to be completed, with a new genetic makeup, but that the virus would have some resulting attributes that would not allow it to exist for very long in the real world.

What gives?

J.

There is no evidence of a human H5N1 reassortant "working". This was tried experimentally almost a decade ago, after the 1997 outbreak in Hong Kong. The mixing experiment was a dismal failure. It was repeated again with more recent isolates from Vietnam or Indonesia, and the results were the same. The reassortants were not as viable or transmissible as the parental strains.

Conceptually, human reassortants with H5N1 make little sense. H5N1 can replicate well in mammalian hosts and has a polybasic cleavage site in H5. Its not a pandemic strain because transmission efficiency in mammals is low and this is almost certainly linked to the receptor binding domain of H5.

A reassortant with H3N2 in H would create H3N1, which would probably not be a pandemic strain because humans have immunity to H3.

There is no experimaent al evidence or natural isolates to support human H5N1 reassortants. Conceptually, it doesn't even make it to hand waving. It remains in the utter nonsense category.

 

[AlaskaDenise]

Re: Avian, human flu coinfection reported in Indonesian teen

Even without a 'deliberate infection', with a seasonal human trivalent influenza vaccine (with adjuvant) it seems possible to exert a cross-reactive immune response: this may be useful if concurrently administer a poor-matched H5N1 vaccine in naive population.

......

Ah......similar to the HK duck case, from a few years ago.

(A <30-day old H9N2 infection saved a flock from a neighborhood-wide H5N1.)

IF it works the same in people, it may lessen H5N1 severity.

However, since the vaccinations work slightly differently in fowl than people, then the cross-reactive immunity may also work differently. Are there any human cases that would test this theory, or would the fruitless searches for "mild" H5N1 cases suffice?

.