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Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009 - April 9, 2009

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Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

niman said:
Commentary

http://www.recombinomics.com/News/04070901/H5N1_Beheira_T2T.html
Click to expand...
Commentary

Toddler to Toddler H5N1 Transmission in Beheira Egypt

Recombinomics Commentary 18:29
April 7, 2009

Boy, age 2, began experiencing fever and cough symptoms on March 27.
Boy, age 2, began experiencing fever, cough and runny nose on March 31.

The above comments describe the two most recently H5N1 confirmed toddlers in Egypt. These two cases were next door neighbors in the Kom Hamada district of Beheira and represent toddler to toddler transmission of H5N1. This cluster follows a spate of toddler cases in Egypt this year. 10 of the 12 confirmed cases have been toddlers and 9 of the 10 toddler cases have been mild. Both patients above are described as being in "good general condition" and will likely be discharged soon. None of the H5N1 cases this year in Egypt have died, which is similar to the mild cases of H5N1 in Egypt in the spring of 2007. However, unlike earlier cases, which included 6 toddlers over a three year period, the percentage of toddler cases has dramatically increased in 2009.

Although the two cases above are said to have had contact with dead or sick poultry, the confirmation of neighboring cases who developed symptoms four days apart is unlikely to be due to two independent poultry infections. There have been no confirmed poultry cases in the Kom Hamada area. Since March 1 there were 24 confirmed H5N1 poultry outbreaks in Egypt, and although 7 were in Beheira, these outbreaks were well to the north and not near the toddler cluster (see updated map). Over 60 outbreaks have been confirmed this season, and none were close to Kom Hamada. Similarly, the toddler case preceding the cluster was in Qena, and there have been no confirmed poultry outbreaks in Qena this season (see updated map).

Although there are clearly more H5N1 outbreaks than those confirmed, the targeting of toddlers raises concerns that old age groups have developed protective immunity, signaling a significant silent spread of H5N1 in Egypt. Over 6000 patients with poultry links have been hospitalized, but less than 1% have tested positive. However, it remains unclear if the low confirmation rate is due to an aggressive testing program, or a lack of sensitivity in the testing.

Confirmed H5N1 clusters have been rare in Egypt have been rare. The largest was the Ghabiya cluster at the end of 2006, but the prior clusters were among relatives and did not have the gap in disease onset dates. The Beheira cluster has the classical gap and there has been no indication that the two toddlers were related. Although it is likely that mild H5N1 has was transmitted human to human, based on the sequence identity between isolates from unrelated cases, the current cluster has the time and space signature associated with human to human transmission.

Sequences from this cluster, as well as testing of toddlers that have symptoms but lack a poultry link would be useful.

.
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

niman said:
Commentary

http://www.recombinomics.com/News/04060903/H5N1_Egypt_Poultry_NOT.html
Click to expand...
Commentary

Lack of Confirmed H5N1 Poultry Linkage To Egyptian Cases

Recombinomics Commentary 21:09
April 6, 2009

Date of report: 5 April 2009
Governorate: Qalioubiya
District: Shoubra el Kheima
Event summary: Boy, age 6, began experiencing symptoms March 22. He was admitted to Ain Shams University hospital March 28 and received Tamiflu on April 3. Infection with avian influenza was confirmed April 5. He was reported in a critical condition under artificial ventilation on April 6. The MOHP reported this was the 63rd case of highly pathogenic avian influenza in Egypt.
Source of report: Amr Kandeel, Undersecretary for preventative affairs, MOHP
Samir Refaie, Head of Epidemiology and Surveillance Unit, MOHP

The above comments describe the most recent confirmed H5N1 case in Egypt. Unlike earlier cases, there is no mention of contact with poultry. The lack of contact is not surprising because of the gap between the admission and confirmation dates. The above detail confirms that treatment was also delayed, which was almost certainly linked to an absence of a poultry contact. In Egypt, over 6000 patients have been hospitalized as suspect H5N1 patients. These cases generally have a poultry link and treatment with Tamiflu is begun prior to receipt of test results. The gap between the admission date of March 28 and treatment date of April 3, strongly suggests that these is no reported link to poultry for this case.

This case follows a spike in confirmed H5N1 in toddlers. The two prior cases were neighbors who lived in Beheira. The 4 day time gap between onset dates strongly suggests that there was toddler to toddler transmission, although both cases have a poultry link. However, the website that describes the patients contains a significant amount of detail, including the district for the two patients, which was Kom Hamada.

The site also details confirmed H5N1 outbreaks in poultry and although there have been 24 outbreaks since March 1, including 7 outbreaks in Beheira, none of the outbreaks were in Kom Hamada, indicating that the Beheira cluster is not linked to H5N1 confirmed poultry. The presence of confirmed H5N1 in the Beheira governorate, but not the Kom Hamada district, raises concerns that the toddlers were not infected by poultry, especially the second case, who was a neighbor of the first case.

The absence of a confirmed H5N1 in the most recent cases in Egypt adds to concerns that the number of mild H5N1 cases is markedly higher than then number of confirmed cases, and like the Beheira cluster, there is human to human transmission that is silently spreading.

More aggressive testing of symptomatic toddlers that lack a poultry contact is warranted.

.
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

niman said:
WHO lag in updates in Indonesia now extending to Egypt

http://www.who.int/csr/disease/avian_influenza/updates/en/index.html
Click to expand...

Indonesia has publicly stated that they will only be reporting human cases every 3-6 months. Egypt, however, has always had timely reporting. The last WHO update for Egypt was on March 30th for the 2.5 year old girl from Qena Governorate. The update noted that she was confirmed on March 26th. News reports on the girl appeared about the 26th or 27th with a WHO update within 4 days of the announcement of the confirmation.

What do think is delaying WHO from providing timely updates from Egypt?
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Laidback Al said:
Indonesia has publicly stated that they will only be reporting human cases every 3-6 months. Egypt, however, has always had timely reporting. The last WHO update for Egypt was on March 30th for the 2.5 year old girl from Qena Governorate. The update noted that she was confirmed on March 26th. News reports on the girl appeared about the 26th or 27th with a WHO update within 4 days of the announcement of the confirmation.

What do think is delaying WHO from providing timely updates from Egypt?
Click to expand...
I was just about to write a commentary. I think they are having problems with a lack of a poultry source as well as the toddler to toddler situation in Beheira. WHO updates are factually correct, but generally nuanced when H2H is involved or a poultry source is missing (and writing nuanced updates takes longer).

The SAIDR site is really a government site, with quotes from the MOPH, so the three most recent cases are confirmed, and the Beheira cluster has been confirmed for almost a week.

I think Qena (their last update) may also be a problem because there is no confirmed poultry outbreak. The vet lab appears to be chasing the human cases and reporting positive poultry in the area (usually right after the human case is confirmed). However, SAIDR has no such poultry positives listed yet for Qena or Beheira (and the most recent case (6M) almost certainly had no know link when the patient was admitted - although it remains unclear why they finally tested for H5N1 - but sometimes the testing is based on the failure of the patient to improve).
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Laidback Al said:
Indonesia has publicly stated that they will only be reporting human cases every 3-6 months. Egypt, however, has always had timely reporting. The last WHO update for Egypt was on March 30th for the 2.5 year old girl from Qena Governorate. The update noted that she was confirmed on March 26th. News reports on the girl appeared about the 26th or 27th with a WHO update within 4 days of the announcement of the confirmation.

What do think is delaying WHO from providing timely updates from Egypt?
Click to expand...
Qena is also the last update from the WHO Mediterranean branch also.

http://www.emro.who.int/index.asp
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Niman,
Is this a result of your commentary?:
The report of the Foundation and the American Medical Laboratory Rekoumibnumiks The cases of infection, which appeared on the children in Beheira in Egypt has recently raised concern of the "silent spread of" bird flu, two years after the wave of infection which broke out in 2007.
Click to expand...
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

There is no proof that any of the recent cases in Egypt are the result of human to human transmission.

Poultry sources were cited for cases # 61 and # 62.

This kind of speculation is not productive.
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Florida1 said:
There is no proof that any of the recent cases in Egypt are the result of human to human transmission.

Poultry sources were cited for cases # 61 and # 62.

This kind of speculation is not productive.
Click to expand...
Please. The "coincidence" argument got VERY old several years ago. 4 day gap in neighbors with confirmed H5N1 is H2H (untested poultry not withstanding).
A four day gap is PROOF (handwaving about some imaginary proof notwithstanding).
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

A quick review of H2H is in order. H5N1 infections of humans are quite rare, so when two people get infected and are very close in space and time, they are almost always connected. The connections can be from exposure to a common source, or the connection can be one infected the other (H2H).

The only real PROOF that distinguishes the two possibilities is disease onset date. If infected by a common source, the disease onset date will be almost identical (same day or 1-2 days apart, because incubation times are generally 2-4 days). However, if one infects the other, there is usually a larger gap because the patient doing the infecting usually already has symptoms, so the patient infected trails by several days.

These gaps are quite common in H5N1 clusters, because most are H2H. Many of these clusters have been written up in peer reviewed journals, and the PROOF is the time gap, such as the 4 days in the Beheira cluster.

Occasionally there are also examples of H2H2H, which are more difficult to deny because of multiple time gaps, but there really isn't much difference in H5N1's that cause H2H or H2H2H. Its just a matter of opportunity.

H2H clusters are VERY easy to call, demands of PROOF, notwithstanding.
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

A 4 day interval between disease onset dates makes human to human transmission a possibility -

It is not the defining event.

Again - H5N1 is endemic in poultry in Egypt. Beheira has a history of H5N1. Many poultry could be getting sick/are sick/dying in the neighborhoods there. H5N1 has been found in feces and feathers.

What are the chances that some poultry between the 2 neighboring households are getting sick/are sick/dying over a few days time span?
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Florida1 said:
A 4 day interval between disease onset dates makes human to human transmission a possibility -

It is not the defining event.

Again - H5N1 is endemic in poultry in Egypt. Beheira has a history of H5N1. Many poultry could be getting sick/are sick/dying in the neighborhoods there. H5N1 has been found in feces and feathers.

What are the chances that some poultry between the 2 neighboring households are getting sick/are sick/dying over a few days time span?
Click to expand...
Four days IS the defining event (no hocus pocus about upcoming H5N1 positive birds required).

The confirmed H5N1 poultry cases anywhere near the Beheira cluster remains at ZERO.

The H5N1 in poultry is MANY orders of magnitude higher than confirmed human cases (minimal math required).
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

What biological tests could deny / confirm h2h?
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Sally said:
What biological tests could deny / confirm h2h?
Click to expand...
None. H2H is confirmed by a gap in disease onset dates PERIOD.
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Sally said:
What biological tests could deny / confirm h2h?
Click to expand...
The difference between common source and H2H is TIME. In both instances the same virus would be involved so the two victims would have the same sequence. If the two sequences were radically different, then an argument could be made for two independent infections. However, that would be an UNcommon source which is uncommon.

Most of the time the sequences would match, regardless of whether the infections were due to a common source or H2H. However, those infected with a common source have the same disease onset date, while H2H produces a gap.

Dead poultry means nothing.
So far no H5N1 positive birds have been reported.
However, even with H5N1 birds, that doesn't mean the birds were the source of the human infection. At a minimum, the sequences would have to match. However, even with a match, the likelihood of independent infection of two neighbors would be MUCH lower than infection of one, who then infected his neighbor.
B2H is RARE
H2H of close contacts is COMMON.

In addition, contact with poultry in the past included:
Drinking duck blood soup (no H5N1 infection required)
Walking past a pond
Living within X miles from a slaughter house
Or as has been suggested on this thread, living within 25 miles of a confirmed outbreak!
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

niman said:
None. H2H is confirmed by a gap in disease onset dates PERIOD.
Click to expand...


"...H5N1 viruses isolated from the two cases were genetically identical except for one non-synonymous nucleotide substitution.

Interpretation

Limited, non-sustained person-to-person transmission of H5N1 virus probably occurred in this family cluster...."



Probable limited person-to-person transmission of highly pathogenic avian influenza A (H5N1) virus in China

Hua Wang MD<sup>a</sup><sup>, </sup><sup>?</sup>, Zijian Feng MD<sup>b</sup><sup>, </sup><sup>?</sup>, Yuelong Shu PhD<sup>c</sup><sup>, </sup><sup>?</sup>, Hongjie Yu MD<sup>b</sup><sup>, </sup><sup>?</sup>, Lei Zhou MD<sup>b</sup>, Rongqiang Zu MD<sup>a</sup>, Yang Huai MD<sup>b</sup>, Jie Dong MD<sup>c</sup>, Changjun Bao MD<sup>a</sup>, Leying Wen MD<sup>c</sup>, Hong Wang MD<sup>d</sup>, Peng Yang PhD<sup>b</sup>, Wei Zhao MD<sup>e</sup>, Libo Dong PhD<sup>c</sup>, Minghao Zhou MD<sup>a</sup>, Qiaohong Liao MD<sup>b</sup>, Haitao Yang MD<sup>a</sup>, Min Wang MD<sup>c</sup>, Xiaojun Lu MD<sup>f</sup>, Zhiyang Shi MD<sup>a</sup>, Wei Wang MD<sup>c</sup>, Ling Gu MD<sup>a</sup>, Fengcai Zhu MD<sup>a</sup>, Qun Li MD<sup>b</sup>, Weidong Yin MBA<sup>g</sup>, Weizhong Yang MD<sup>b</sup>, Prof Dexin Li MD<sup>c</sup>, Timothy M Uyeki MD<sup>h</sup> and Prof Yu Wang PhD<sup>b</sup><sup>, </sup><sup></sup><sup>, </sup><sup></sup>
<sup>a</sup>Jiangsu Provincial Centre for Disease Control and Prevention, Nanjing, China
<sup>b</sup>Office for Disease Control and Emergency Response, Chinese Centre for Disease Control and Prevention (China CDC), Beijing, China
<sup>c</sup>State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Viral Disease Control and Prevention, China CDC, Beijing, China
<sup>d</sup>Jiangsu Provincial People's Hospital, Nanjing, China
<sup>e</sup>Nanjing Secondary People's Hospital, Nanjing, China
<sup>f</sup>Najing Centre for Disease Control and Prevention, Nanjing, China
<sup>g</sup>Sinovac Biotech Co, Beijing, China
<sup>h</sup>Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA


http://www.flutrackers.com/forum/showpost.php?p=147506&postcount=2
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Florida1 said:
"...H5N1 viruses isolated from the two cases were genetically identical except for one non-synonymous nucleotide substitution.

Interpretation

Limited, non-sustained person-to-person transmission of H5N1 virus probably occurred in this family cluster...."



Probable limited person-to-person transmission of highly pathogenic avian influenza A (H5N1) virus in China

Hua Wang MD<SUP>a</SUP><SUP>, </SUP><SUP>?</SUP>, Zijian Feng MD<SUP>b</SUP><SUP>, </SUP><SUP>?</SUP>, Yuelong Shu PhD<SUP>c</SUP><SUP>, </SUP><SUP>?</SUP>, Hongjie Yu MD<SUP>b</SUP><SUP>, </SUP><SUP>?</SUP>, Lei Zhou MD<SUP>b</SUP>, Rongqiang Zu MD<SUP>a</SUP>, Yang Huai MD<SUP>b</SUP>, Jie Dong MD<SUP>c</SUP>, Changjun Bao MD<SUP>a</SUP>, Leying Wen MD<SUP>c</SUP>, Hong Wang MD<SUP>d</SUP>, Peng Yang PhD<SUP>b</SUP>, Wei Zhao MD<SUP>e</SUP>, Libo Dong PhD<SUP>c</SUP>, Minghao Zhou MD<SUP>a</SUP>, Qiaohong Liao MD<SUP>b</SUP>, Haitao Yang MD<SUP>a</SUP>, Min Wang MD<SUP>c</SUP>, Xiaojun Lu MD<SUP>f</SUP>, Zhiyang Shi MD<SUP>a</SUP>, Wei Wang MD<SUP>c</SUP>, Ling Gu MD<SUP>a</SUP>, Fengcai Zhu MD<SUP>a</SUP>, Qun Li MD<SUP>b</SUP>, Weidong Yin MBA<SUP>g</SUP>, Weizhong Yang MD<SUP>b</SUP>, Prof Dexin Li MD<SUP>c</SUP>, Timothy M Uyeki MD<SUP>h</SUP> and Prof Yu Wang PhD<SUP>b</SUP><SUP>, </SUP><SUP></SUP><SUP>, </SUP><SUP></SUP>
<SUP>a</SUP>Jiangsu Provincial Centre for Disease Control and Prevention, Nanjing, China
<SUP>b</SUP>Office for Disease Control and Emergency Response, Chinese Centre for Disease Control and Prevention (China CDC), Beijing, China
<SUP>c</SUP>State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Viral Disease Control and Prevention, China CDC, Beijing, China
<SUP>d</SUP>Jiangsu Provincial People's Hospital, Nanjing, China
<SUP>e</SUP>Nanjing Secondary People's Hospital, Nanjing, China
<SUP>f</SUP>Najing Centre for Disease Control and Prevention, Nanjing, China
<SUP>g</SUP>Sinovac Biotech Co, Beijing, China
<SUP>h</SUP>Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA


http://www.flutrackers.com/forum/showpost.php?p=147506&postcount=2
Click to expand...
Please. The time gap between the father and son was about a week.
Sequence identity means NOTHING.
 
Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Re: Egypt - Human Confirmed/Suspected Bird Flu Cases, Feb 8, 2009+

Florida1 said:
"...H5N1 viruses isolated from the two cases were genetically identical except for one non-synonymous nucleotide substitution.

Interpretation

Limited, non-sustained person-to-person transmission of H5N1 virus probably occurred in this family cluster...."



Probable limited person-to-person transmission of highly pathogenic avian influenza A (H5N1) virus in China

Hua Wang MD<SUP>a</SUP><SUP>, </SUP><SUP>‡</SUP>, Zijian Feng MD<SUP>b</SUP><SUP>, </SUP><SUP>‡</SUP>, Yuelong Shu PhD<SUP>c</SUP><SUP>, </SUP><SUP>‡</SUP>, Hongjie Yu MD<SUP>b</SUP><SUP>, </SUP><SUP>‡</SUP>, Lei Zhou MD<SUP>b</SUP>, Rongqiang Zu MD<SUP>a</SUP>, Yang Huai MD<SUP>b</SUP>, Jie Dong MD<SUP>c</SUP>, Changjun Bao MD<SUP>a</SUP>, Leying Wen MD<SUP>c</SUP>, Hong Wang MD<SUP>d</SUP>, Peng Yang PhD<SUP>b</SUP>, Wei Zhao MD<SUP>e</SUP>, Libo Dong PhD<SUP>c</SUP>, Minghao Zhou MD<SUP>a</SUP>, Qiaohong Liao MD<SUP>b</SUP>, Haitao Yang MD<SUP>a</SUP>, Min Wang MD<SUP>c</SUP>, Xiaojun Lu MD<SUP>f</SUP>, Zhiyang Shi MD<SUP>a</SUP>, Wei Wang MD<SUP>c</SUP>, Ling Gu MD<SUP>a</SUP>, Fengcai Zhu MD<SUP>a</SUP>, Qun Li MD<SUP>b</SUP>, Weidong Yin MBA<SUP>g</SUP>, Weizhong Yang MD<SUP>b</SUP>, Prof Dexin Li MD<SUP>c</SUP>, Timothy M Uyeki MD<SUP>h</SUP> and Prof Yu Wang PhD<SUP>b</SUP><SUP>, </SUP><SUP></SUP><SUP>, </SUP><SUP></SUP>
<SUP>a</SUP>Jiangsu Provincial Centre for Disease Control and Prevention, Nanjing, China
<SUP>b</SUP>Office for Disease Control and Emergency Response, Chinese Centre for Disease Control and Prevention (China CDC), Beijing, China
<SUP>c</SUP>State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Viral Disease Control and Prevention, China CDC, Beijing, China
<SUP>d</SUP>Jiangsu Provincial People's Hospital, Nanjing, China
<SUP>e</SUP>Nanjing Secondary People's Hospital, Nanjing, China
<SUP>f</SUP>Najing Centre for Disease Control and Prevention, Nanjing, China
<SUP>g</SUP>Sinovac Biotech Co, Beijing, China
<SUP>h</SUP>Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA


http://www.flutrackers.com/forum/showpost.php?p=147506&postcount=2
Click to expand...
As noted on Dec 8, 2007

http://www.recombinomics.com/News/12080702/H5N1_Jiangsu_H2H.html

Likely Human to Human H5N1 Transmission in Jiangsu China

Recombinomics Commentary
December 8, 2007

Joanna Brent, a Beijing-based WHO spokeswoman, said the father began presenting symptoms on Monday and was confirmed as having the virus on Wednesday. She said he was being monitored in hospital.

'Because the possibility of human to human transmission cannot be ruled out, we will be monitoring this case closely,' Brent told reporters.

'If it is found to be easily passed between humans, we would be concerned,' Ms Brent said.

Ms Brent said there was no evidence that the man had been infected by his 24-year-old son, who died on Dec 2, but said the possibility could not yet be eliminated.

Ms Brent said it was also possible that both men were infected by the same bird, or that they were infected separately from different sources.

The above comments by WHO offer multiple possibilities for transmission within the Jiangsu cluster, but the transmission is likely to be human-to-human because the son infected his father.

H5N1 clusters give rise to two main possibilities, infection from a common source or human-to-human transmission. These two possibilities are largely decided by the disease onset dates. Since confirmed H5N1 human cases are very rare, it is likely that two infections within one household are linked.

If a common source (bird or human) is involved, both family members will develop symptoms at a similar time. If the index case infects the family member, there will be a gap in the disease onset dates. In this cluster, the son developed symptoms on November 24, while the father developed symptoms on December 3. This gap would make human-to-human transmission likely.

This likelihood is increased because the index case has no known contact with infected poultry, decreasing the likelihood that the father and son were infected by a common source.

This cluster has attracted significant attention in the popular press, in part because of the gap in disease onset dates. However, there are additional reports in the Chinese press indicating the father died on Thursday and the mother and girlfriend of the index case have symptoms. If H5N1 confirmed, the likelihood of human-to-human transmission would increase markedly.
 
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