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Human avian influenza in Azerbaijan, February?March 2006
Published May 5, 2006
On 4 March, 6 patients, 1 of whom in a severe condition, were referred to the Scientific Research Institute of Lung Diseases Hospital in Baku, where they were admitted or isolated.
On 6 March, the Ministry of Health (MoH) in the Republic of Azerbaijan reported to the WHO Regional Office for Europe a cluster of 9 suspected cases of human avian influenza (HAI), including 2 deaths. The patients, 8 from the same family and 1 from a neighbouring family in Daikyand settlement in Salyan District, south-east of Baku, became ill over a 2-week period, with dates of onset from 15 February to 4 March. Their symptoms included fever, headache, cough and meningeal signs. The clinical presentation was varied, which obscured and delayed the suspicion of HAI.
On 7 March, 5 patients who had displayed no further symptoms were discharged from hospital, where they had received a 3-day course of oseltamivir (150mg/day), and returned home to Daikyand.
On 13 March, a field laboratory with real-time polymerase chain reaction (RT-PCR) capacity to detect influenza A/H5 virus, was established by the US Navy Medical Research Unit 3 (NAMRU-3), Cairo (Egypt), at the Anti-Plague Station (APS) in Baku. On the same day, throat swabs and/or blood specimens, including postmortem specimens, obtained from 11 individuals for whom HAI diagnosis was considered, were tested. Influenza A/H5 virus infection was detected in samples from 5 deceased individuals (including 4 from Daikyand and 1 from Tarter, another district in central eastern Azerbaijan). All samples were also sent for confirmation to the WHO Collaborating Centre for Influenza at the National Institute for Medical Research (NIMR), Mill Hill, United Kingdom.
On 14 March, a joint team of staff from the MoH, APS and WHO conducted a field investigation in Daikyand settlement. That day, 2 children from the same family, who had been admitted to hospital in Baku from 4 to 7 March, were re-hospitalized with fever.
On 18 March, the presence of influenza A/H5N1 virus infection was confirmed at NIMR in samples obtained from 7 patients, including 2 additional individuals whose samples had tested negative at the field laboratory. Before the notification of the first human cases, a WHO team had visited the country in January, at the request of the MoH, to assess the risk of spread of H5N1 to humans because of the reported H5N1 suspected outbreaks in wild birds and poultry both in Azerbaijan and neighbouring Turkey. Upon confirmation of transmission of the H5N1 virus in animals, before the human cases, a national awareness campaign had been initiated.
This report describes the control activities implemented and summarizes the epidemiological and clinical findings from the affected areas. Response to the cluster of HAI cases On 15 March, further to a request by the MoH, the WHO-led international team was strengthened by experts in infection control, clinical management, epidemiology, laboratory work and communication. The team, which comprised 11 individuals representing 51 institutions and organizations, was deployed for nearly 3 weeks to assist in the response.
The team worked in Salyan and visited additional districts identified as being at risk for HAI; where mass bird die-offs had been witnessed or rumoured or where influenza A/H5 virus infection had been laboratory-confirmed in wild birds or poultry. Control activities focused on (i) social mobilization campaigns, coordinated by UNICEF, to encourage practices aimed at reducing the risk of infection and at promoting acceptance of surveillance practices and referral of suspected HAI cases to designated isolation units; (ii) epidemiological surveillance, including active case-finding; (iii) timely laboratory diagnosis of influenza A/H5 virus infection by the NAMRU-3 field laboratory and shipment of specimens to NIMR for confirmation; (iv) health monitoring of contacts, including health-care workers,associated with suspected HAI cases during the 7 days from the date of last exposure to the suspected HAI case; (v) safe transport and case management of patients for whom HAI diagnosis was considered or confirmed at designated isolation units in Baku.
Social mobilization
In late February 2006, social mobilization campaigns started in Azerbaijan following confirmation of influenza A/H5N1 virus infection in wild birds found in the coastal area near Baku and in poultry at farms in Bilasuvar and Khyzy districts. (The infection was also detected in wild ducks from Agdam District in March 2006.) These campaigns were developed by UNICEF in collaboration with the MoH and were designed to inform the general public about the risk of exposure to and mode of transmission of influenza A/H5 virus.
The State Commission, empowered to manage avian influenza activities at national level, was also in charge of public announcements. On the evening when the first HAI cases were confirmed locally, the MoH issued a press release providing this information.
The MoH, in conjunction with WHO, regularly reported on developments and actions taken by public health authorities. However, this was not always coordinated with information on preventive measures implemented by the veterinary authorities.
During the field visits to Daikyand settlement, it emerged that risk perception at community level was limited and that local residents persistently denied avian influenza as the cause of the illnesses and deaths of affected community members.
The fact that hunting of wild birds was declared illegal and that the matter of compensation, hunting and exhumation of bodies was not addressed in messages to the population.
On 10 March, the surveillance team, which included members from the MoH, APS, the Republican Centre of Sanitary Hygiene and WHO, developed a case definition2 and a standardized case investigation form for suspected HAI cases, which was translated into Azeri and Russian.
On 13 March, the form was approved by the MoH for use within the entire country. An Epiinfo 2000 database was created in English and Russian for data entry and analysis. Surveillance activities were later extended to other at-risk districts (Agdaz, Ardam, Astara, Bilasuvar, Deveci, Galilabad, Khachmaz, Lenkoran, Massally, Neftchala, Salyan, Tarter and Xizi). In each of these districts, epidemiologists were trained to carry out and document investigations of suspected HAI cases.
As of 24 April, 22 individuals, including 6 deaths, had been investigated for HAI in 6 districts (Khachmaz, Neftchela, Tarter, Sabail, Salyan and Surakhana), all of whom were hospitalized. Following laboratory testing and clinical assessment, 7 confirmed cases, including 4 fatalities, were reported in Daikyand settlement; 2 fatal cases, 1 confirmed and 1 probable, were reported in Bayim-Sarov camp for internally displaced persons (IDP), Tarter District.
**********************
Notes:
2 HAI cases were classified according to the following case categories:
Possible case: any individual with unexplained axillary temperature $38 ?C; AND one or more of the following symptoms: cough, sore throat, shortness of breath; AND resident in an area where influenza A/H5 virus infection has been suspected (i.e. undiagnosed mass poultry die-offs, dead wild birds seen or probable/confirmed human cases from the area);
Probable case: a possible case AND that had, within 7 days prior to the onset of symptoms, one or more of the following: close contact (within 1 m) with a probable or confirmed case; close contact with sick or dead poultry or with areas heavily contaminated by their droppings; close contact with wild birds or with areas heavily contaminated by their droppings; consumption of undercooked bird meat or eggs; worked in laboratory processing samples (human or animal) suspected of containing influenza A/H5 influenza virus;
Confirmed case: a probable case for whom a specimen tested positive for influenza A/H5 virus infection by PCR.
**************************
Laboratory diagnosis
As of 27 March, 108 clinical specimens, including throat and nasal swabs, sera, and rectal swabs, obtained from 20 individuals for whom influenza A/H5 virus infection was considered and from 32 of their contacts had been tested.
All clinical specimens were tested for the presence of influenza A/H5 virus infection by RT-PCR at the NAMRU-3 (portable) field laboratory using a two-step procedure, involving testing for ?flu A (matrix gene)? followed by a second round for H5.
Regardless of the results obtained in the field, all specimens were transferred to NIMR for confirmation by RT-PCR for influenza A/H5 virus (Asian lineage), haemagglutination inhibition test, virus isolation in embryonated eggs and MDCK cells, and genomic sequencing.
The NAMRU-3 field laboratory detected 7 cases of influenza A/H5 virus infection and NIMR 8 cases. Of the 3 specimens that tested negative by the NAMRU-3 field laboratory and positive at NIMR, 2 were from patients from whom additional specimens subsequently tested positive at the NAMRU-3 field laboratory. NIMR confirmed all positive results on specimens tested by the field laboratory. No specimens from contacts tested positive for influenza A/H5 virus infection.
Virus samples were isolated from 3 cases. Phylogenetic comparison of H5 haemagglutinins shows that all genes are of avian virus origin and closely related to the sequences of the corresponding genes of other ?Qinghai Lake? H5N1 viruses isolated from avian species (including viruses isolated from a swan in Azerbaijan in February 2006, A/swan/Italy/179/06, and from a swan in Islamic Republic of Iran, A/swan/Iran/754/2006, and humans (in Turkey, Iraq and Egypt)).
These viruses are thus distinguished from the H5 haemagglutinin of viruses isolated in east Asian countries, including China, Indonesia and Viet Nam. Sequencing data indicate that the viruses are likely to be sensitive to amantadine and rimantadine.
The rapid establishment of the RT-PCR field laboratory in Azerbaijan provided timely and reliable diagnosis of influenza A/H5 virus infection, as shipping procedures to NIMR for confirmation were not well established and subject to delay. The specificity of the field laboratory RT-PCR was supported by the absence of false-positive results.
Management of cases and contacts
Technical health care at the regional level is limited in Azerbaijan, and mechanical ventilation was generally not available at district hospitals. In order to ensure the highest degree of access to medical support, all individuals for whom diagnosis of influenza A/H5 virus infection was considered were mobilized to designated reference hospitals in Baku; established at the Scientific Research Institute of Lung Diseases Hospital, Abulfaz Karayev Childrens Hospital and Hospital 7 in Baku.
Following clinical assessment by a team comprising a local physician, an MoH representative and a WHO case management expert, patients fulfilling the definition of a probable case were admitted to an isolation unit at the hospital.
Probable and confirmed cases received oseltamivir (150 mg/day for 5 days), and antibiotic and critical care support as needed. Of note in the case management protocol was the early establishment of oxygen saturation monitoring and provision of continuous oxygen therapy. Severe hypoxia, which appears to be under-recognized and is treated late in children with prolonged course of viral pneumonia, may lead to decompensation and contribute to multi-organ failure documented in previous HAI cases.
Contacts of confirmed and probable cases, including health-care workers, were subject to health monitoring by the surveillance teams.
Cluster in Daikyand settlement, Salyan District
Data regarding an HAI cluster detected in Daikyand settlement were gathered from multiple sources, including medical records at designated for avian influenza health facilities in Baku, district medical officers and epidemiologists and family members. An analysis of available data is presented in the following section.
The first case, identified retrospectively on 1 March, fell ill on 15 February, whereas the date of onset of the most recent case was 4 March, with discharge from hospital on 12 April. Between 15 February and 12 April, 7 confirmed cases, including 4 fatalities (case-fatality rate, 57%) were noted.
The median interval between onset of symptoms and death was 9 days (mean: 11.2 days; range 8?19 days).
Patients? ages ranged from 10 to 20 years (mean: 16 years;median: 17 years); 5 of 7 cases were females aged 15?20 years, 4 of whom died.
All cases came from neighbouring and related families.
Although the investigation of the possible source of infection was complex because of the illegality of hunting wild birds, it emerged that a massive die-off of swans had occurred in the area from February 2006. The index case was probably infected while de-feathering a swan in early February. This practice, largely involving women and thought to have been repeated by different individuals over time, is considered to be the most plausible cause of exposure to the influenza A/H5 virus. This cluster would constitute the first event where wild birds constitute the most likely source of human influenza A/H5 virus infection.
However, the difficulties in gathering accurate information, the reported dates of onset and the relatively crowded living conditions do not exclude the possibility of human-to-human transmission.
Among the 7 cases, the signs and symptoms reported included fever (6), pneumonia (6) cough (5), sore throat (4), shortness of breath (1), stomach pain (1), body aches (1) and meningeal signs (1).
All 7 cases were admitted to health-care facilities in Baku during the course of their illness; 4 were isolated in designated facilities.
Cluster in Bayim-Sarov, Tarter District
On 28 February, a 24-year-old male resident in Bayim-Sarov IDP camp, developed shortness of breath, weakness, headache and was sub-febrile (37.5 ?C). The next day, he was referred from the nearby tuberculosis dispensary in Barda to the Scientific Research Institute of Lung Diseases Hospital in Baku, where he died on 3 March with diagnosis of reactivated TB. No samples were preserved for examinament tion. His body was returned home to Tarter that day, where it was mourned in very close physical contact by his 18-year-old sister.
On 4 March, the sister developed similar symptoms to her brother and, on 6 March, was referred from the TB dispensary to Hospital 1 in Baku, where she died 3 days later. The samples obtained tested positive for influenza A/H5 virus infection by RT-PCR at the NAMRU-3 field laboratory. These results were confirmed at NIMR.
In February, a die-off of wild birds was reported in Tarter, with no reports of sick poultry in the area. Family members denied any history of exposure of the 2 siblings to sick or dead domestic or wild birds, or to other animal species known to be susceptible to influenza A/H5 virus infection.
The family did not confirm information to the investigation team by key community informants, according to which the 2 siblings had purchased a dead turkey, reputed to have been ill, de-feathered it, prepared it and ate it. No further individuals were suspected, or investigated for HAI in the settlement.
For further information, please contact: euroalert _at_ euro.who.int
http://www.who.int/wer/2006/wer8118.pdf
Published May 5, 2006
On 4 March, 6 patients, 1 of whom in a severe condition, were referred to the Scientific Research Institute of Lung Diseases Hospital in Baku, where they were admitted or isolated.
On 6 March, the Ministry of Health (MoH) in the Republic of Azerbaijan reported to the WHO Regional Office for Europe a cluster of 9 suspected cases of human avian influenza (HAI), including 2 deaths. The patients, 8 from the same family and 1 from a neighbouring family in Daikyand settlement in Salyan District, south-east of Baku, became ill over a 2-week period, with dates of onset from 15 February to 4 March. Their symptoms included fever, headache, cough and meningeal signs. The clinical presentation was varied, which obscured and delayed the suspicion of HAI.
On 7 March, 5 patients who had displayed no further symptoms were discharged from hospital, where they had received a 3-day course of oseltamivir (150mg/day), and returned home to Daikyand.
On 13 March, a field laboratory with real-time polymerase chain reaction (RT-PCR) capacity to detect influenza A/H5 virus, was established by the US Navy Medical Research Unit 3 (NAMRU-3), Cairo (Egypt), at the Anti-Plague Station (APS) in Baku. On the same day, throat swabs and/or blood specimens, including postmortem specimens, obtained from 11 individuals for whom HAI diagnosis was considered, were tested. Influenza A/H5 virus infection was detected in samples from 5 deceased individuals (including 4 from Daikyand and 1 from Tarter, another district in central eastern Azerbaijan). All samples were also sent for confirmation to the WHO Collaborating Centre for Influenza at the National Institute for Medical Research (NIMR), Mill Hill, United Kingdom.
On 14 March, a joint team of staff from the MoH, APS and WHO conducted a field investigation in Daikyand settlement. That day, 2 children from the same family, who had been admitted to hospital in Baku from 4 to 7 March, were re-hospitalized with fever.
On 18 March, the presence of influenza A/H5N1 virus infection was confirmed at NIMR in samples obtained from 7 patients, including 2 additional individuals whose samples had tested negative at the field laboratory. Before the notification of the first human cases, a WHO team had visited the country in January, at the request of the MoH, to assess the risk of spread of H5N1 to humans because of the reported H5N1 suspected outbreaks in wild birds and poultry both in Azerbaijan and neighbouring Turkey. Upon confirmation of transmission of the H5N1 virus in animals, before the human cases, a national awareness campaign had been initiated.
This report describes the control activities implemented and summarizes the epidemiological and clinical findings from the affected areas. Response to the cluster of HAI cases On 15 March, further to a request by the MoH, the WHO-led international team was strengthened by experts in infection control, clinical management, epidemiology, laboratory work and communication. The team, which comprised 11 individuals representing 51 institutions and organizations, was deployed for nearly 3 weeks to assist in the response.
The team worked in Salyan and visited additional districts identified as being at risk for HAI; where mass bird die-offs had been witnessed or rumoured or where influenza A/H5 virus infection had been laboratory-confirmed in wild birds or poultry. Control activities focused on (i) social mobilization campaigns, coordinated by UNICEF, to encourage practices aimed at reducing the risk of infection and at promoting acceptance of surveillance practices and referral of suspected HAI cases to designated isolation units; (ii) epidemiological surveillance, including active case-finding; (iii) timely laboratory diagnosis of influenza A/H5 virus infection by the NAMRU-3 field laboratory and shipment of specimens to NIMR for confirmation; (iv) health monitoring of contacts, including health-care workers,associated with suspected HAI cases during the 7 days from the date of last exposure to the suspected HAI case; (v) safe transport and case management of patients for whom HAI diagnosis was considered or confirmed at designated isolation units in Baku.
Social mobilization
In late February 2006, social mobilization campaigns started in Azerbaijan following confirmation of influenza A/H5N1 virus infection in wild birds found in the coastal area near Baku and in poultry at farms in Bilasuvar and Khyzy districts. (The infection was also detected in wild ducks from Agdam District in March 2006.) These campaigns were developed by UNICEF in collaboration with the MoH and were designed to inform the general public about the risk of exposure to and mode of transmission of influenza A/H5 virus.
The State Commission, empowered to manage avian influenza activities at national level, was also in charge of public announcements. On the evening when the first HAI cases were confirmed locally, the MoH issued a press release providing this information.
The MoH, in conjunction with WHO, regularly reported on developments and actions taken by public health authorities. However, this was not always coordinated with information on preventive measures implemented by the veterinary authorities.
During the field visits to Daikyand settlement, it emerged that risk perception at community level was limited and that local residents persistently denied avian influenza as the cause of the illnesses and deaths of affected community members.
The fact that hunting of wild birds was declared illegal and that the matter of compensation, hunting and exhumation of bodies was not addressed in messages to the population.
On 10 March, the surveillance team, which included members from the MoH, APS, the Republican Centre of Sanitary Hygiene and WHO, developed a case definition2 and a standardized case investigation form for suspected HAI cases, which was translated into Azeri and Russian.
On 13 March, the form was approved by the MoH for use within the entire country. An Epiinfo 2000 database was created in English and Russian for data entry and analysis. Surveillance activities were later extended to other at-risk districts (Agdaz, Ardam, Astara, Bilasuvar, Deveci, Galilabad, Khachmaz, Lenkoran, Massally, Neftchala, Salyan, Tarter and Xizi). In each of these districts, epidemiologists were trained to carry out and document investigations of suspected HAI cases.
As of 24 April, 22 individuals, including 6 deaths, had been investigated for HAI in 6 districts (Khachmaz, Neftchela, Tarter, Sabail, Salyan and Surakhana), all of whom were hospitalized. Following laboratory testing and clinical assessment, 7 confirmed cases, including 4 fatalities, were reported in Daikyand settlement; 2 fatal cases, 1 confirmed and 1 probable, were reported in Bayim-Sarov camp for internally displaced persons (IDP), Tarter District.
**********************
Notes:
2 HAI cases were classified according to the following case categories:
Possible case: any individual with unexplained axillary temperature $38 ?C; AND one or more of the following symptoms: cough, sore throat, shortness of breath; AND resident in an area where influenza A/H5 virus infection has been suspected (i.e. undiagnosed mass poultry die-offs, dead wild birds seen or probable/confirmed human cases from the area);
Probable case: a possible case AND that had, within 7 days prior to the onset of symptoms, one or more of the following: close contact (within 1 m) with a probable or confirmed case; close contact with sick or dead poultry or with areas heavily contaminated by their droppings; close contact with wild birds or with areas heavily contaminated by their droppings; consumption of undercooked bird meat or eggs; worked in laboratory processing samples (human or animal) suspected of containing influenza A/H5 influenza virus;
Confirmed case: a probable case for whom a specimen tested positive for influenza A/H5 virus infection by PCR.
**************************
Laboratory diagnosis
As of 27 March, 108 clinical specimens, including throat and nasal swabs, sera, and rectal swabs, obtained from 20 individuals for whom influenza A/H5 virus infection was considered and from 32 of their contacts had been tested.
All clinical specimens were tested for the presence of influenza A/H5 virus infection by RT-PCR at the NAMRU-3 (portable) field laboratory using a two-step procedure, involving testing for ?flu A (matrix gene)? followed by a second round for H5.
Regardless of the results obtained in the field, all specimens were transferred to NIMR for confirmation by RT-PCR for influenza A/H5 virus (Asian lineage), haemagglutination inhibition test, virus isolation in embryonated eggs and MDCK cells, and genomic sequencing.
The NAMRU-3 field laboratory detected 7 cases of influenza A/H5 virus infection and NIMR 8 cases. Of the 3 specimens that tested negative by the NAMRU-3 field laboratory and positive at NIMR, 2 were from patients from whom additional specimens subsequently tested positive at the NAMRU-3 field laboratory. NIMR confirmed all positive results on specimens tested by the field laboratory. No specimens from contacts tested positive for influenza A/H5 virus infection.
Virus samples were isolated from 3 cases. Phylogenetic comparison of H5 haemagglutinins shows that all genes are of avian virus origin and closely related to the sequences of the corresponding genes of other ?Qinghai Lake? H5N1 viruses isolated from avian species (including viruses isolated from a swan in Azerbaijan in February 2006, A/swan/Italy/179/06, and from a swan in Islamic Republic of Iran, A/swan/Iran/754/2006, and humans (in Turkey, Iraq and Egypt)).
These viruses are thus distinguished from the H5 haemagglutinin of viruses isolated in east Asian countries, including China, Indonesia and Viet Nam. Sequencing data indicate that the viruses are likely to be sensitive to amantadine and rimantadine.
The rapid establishment of the RT-PCR field laboratory in Azerbaijan provided timely and reliable diagnosis of influenza A/H5 virus infection, as shipping procedures to NIMR for confirmation were not well established and subject to delay. The specificity of the field laboratory RT-PCR was supported by the absence of false-positive results.
Management of cases and contacts
Technical health care at the regional level is limited in Azerbaijan, and mechanical ventilation was generally not available at district hospitals. In order to ensure the highest degree of access to medical support, all individuals for whom diagnosis of influenza A/H5 virus infection was considered were mobilized to designated reference hospitals in Baku; established at the Scientific Research Institute of Lung Diseases Hospital, Abulfaz Karayev Childrens Hospital and Hospital 7 in Baku.
Following clinical assessment by a team comprising a local physician, an MoH representative and a WHO case management expert, patients fulfilling the definition of a probable case were admitted to an isolation unit at the hospital.
Probable and confirmed cases received oseltamivir (150 mg/day for 5 days), and antibiotic and critical care support as needed. Of note in the case management protocol was the early establishment of oxygen saturation monitoring and provision of continuous oxygen therapy. Severe hypoxia, which appears to be under-recognized and is treated late in children with prolonged course of viral pneumonia, may lead to decompensation and contribute to multi-organ failure documented in previous HAI cases.
Contacts of confirmed and probable cases, including health-care workers, were subject to health monitoring by the surveillance teams.
Cluster in Daikyand settlement, Salyan District
Data regarding an HAI cluster detected in Daikyand settlement were gathered from multiple sources, including medical records at designated for avian influenza health facilities in Baku, district medical officers and epidemiologists and family members. An analysis of available data is presented in the following section.
The first case, identified retrospectively on 1 March, fell ill on 15 February, whereas the date of onset of the most recent case was 4 March, with discharge from hospital on 12 April. Between 15 February and 12 April, 7 confirmed cases, including 4 fatalities (case-fatality rate, 57%) were noted.
The median interval between onset of symptoms and death was 9 days (mean: 11.2 days; range 8?19 days).
Patients? ages ranged from 10 to 20 years (mean: 16 years;median: 17 years); 5 of 7 cases were females aged 15?20 years, 4 of whom died.
All cases came from neighbouring and related families.
Although the investigation of the possible source of infection was complex because of the illegality of hunting wild birds, it emerged that a massive die-off of swans had occurred in the area from February 2006. The index case was probably infected while de-feathering a swan in early February. This practice, largely involving women and thought to have been repeated by different individuals over time, is considered to be the most plausible cause of exposure to the influenza A/H5 virus. This cluster would constitute the first event where wild birds constitute the most likely source of human influenza A/H5 virus infection.
However, the difficulties in gathering accurate information, the reported dates of onset and the relatively crowded living conditions do not exclude the possibility of human-to-human transmission.
Among the 7 cases, the signs and symptoms reported included fever (6), pneumonia (6) cough (5), sore throat (4), shortness of breath (1), stomach pain (1), body aches (1) and meningeal signs (1).
All 7 cases were admitted to health-care facilities in Baku during the course of their illness; 4 were isolated in designated facilities.
Cluster in Bayim-Sarov, Tarter District
On 28 February, a 24-year-old male resident in Bayim-Sarov IDP camp, developed shortness of breath, weakness, headache and was sub-febrile (37.5 ?C). The next day, he was referred from the nearby tuberculosis dispensary in Barda to the Scientific Research Institute of Lung Diseases Hospital in Baku, where he died on 3 March with diagnosis of reactivated TB. No samples were preserved for examinament tion. His body was returned home to Tarter that day, where it was mourned in very close physical contact by his 18-year-old sister.
On 4 March, the sister developed similar symptoms to her brother and, on 6 March, was referred from the TB dispensary to Hospital 1 in Baku, where she died 3 days later. The samples obtained tested positive for influenza A/H5 virus infection by RT-PCR at the NAMRU-3 field laboratory. These results were confirmed at NIMR.
In February, a die-off of wild birds was reported in Tarter, with no reports of sick poultry in the area. Family members denied any history of exposure of the 2 siblings to sick or dead domestic or wild birds, or to other animal species known to be susceptible to influenza A/H5 virus infection.
The family did not confirm information to the investigation team by key community informants, according to which the 2 siblings had purchased a dead turkey, reputed to have been ill, de-feathered it, prepared it and ate it. No further individuals were suspected, or investigated for HAI in the settlement.
For further information, please contact: euroalert _at_ euro.who.int
http://www.who.int/wer/2006/wer8118.pdf
