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Pakistan - BF Suspected Human Cases December 18, 2007 to Feb 2, 2008

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Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

<TABLE><TBODY><TR><TD>
Delay in H5-report | People fear the worst​
</TD></TR><TR><TD>
</TD></TR><TR><TD>Staff Reporter
</TD></TR><TR><TD>ISLAMABAD: The Health Ministry and National Institute of Health have yet to confirm whether the infected person got bird flu virus from chicken.

On the other hand, people fear the worst because of the ministry dragging its feet over the matter. A source said the method used to confirm H5 virus was called real-time RT PCR, which did not take more than five hours to confirm the result.

Ten days have elapsed since samples were sent for laboratory examination.:tiphat:

http://www.thepost.com.pk/IsbNews.aspx?dtlid=135848&catid=17
</TD></TR></TBODY></TABLE>
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

WHO confirms H5N1 case in Pakistan cluster

Robert Roos
purple-speck.gif
News Editor

Dec 27, 2007 (CIDRAP News) ? The World Health Organization (WHO) today announced its first confirmation of a human case of H5N1 avian influenza in Pakistan, in a young man who was part of a family cluster of suspected cases and died of the disease.
The man was one of several brothers who fell ill after caring for another brother?a veterinarian who had become ill after helping to cull chickens in the Peshawar area. The WHO's announcement today thus signals not only Pakistan's first confirmed human case, but also a rare instance of apparent human-to-human transmission. The WHO said the virus did not spread beyond the family.
The WHO posted a brief statement today saying the agency's H5 reference laboratory in Cairo and its Collaborating Center for Reference and Research on Influenza in London identified the H5N1 virus in samples from one member of the family group of patients. The agency said additional analysis, including gene sequencing, is under way.
Citing information from Pakistan's health ministry, John Rainford, a WHO spokesman in Geneva, identified the man as a 25-year-old from the Peshawar area who became ill on Nov 21, was hospitalized Nov 23, and died Nov 28.
"He is the third of four brothers who developed proven or suspected pneumonia with illness onset dates between 29 October and 21 November," Rainford told CIDRAP News. "The brothers provided care for one another and had close personal contact in both the home and hospital."
According to previous reports, the family group was among eight people in Pakistan's North-West Frontier province, near the Afghan border, who were previously diagnosed with avian flu on the basis of preliminary tests in Pakistan. The eight included four brothers and a cousin from the same family, plus three other people. Another brother also had a flu-like illness but died without being tested.
The other patients who tested positive have been described as a man and his niece who were involved in poultry culling, plus a male farm worker.
The WHO said previously that limited person-to-person transmission might have occurred among close contacts in the Pakistan situation. Today the agency stated, "The preliminary risk assessment found no evidence of sustained or community human-to-human transmission.
"All identified close contacts including the other members of the affected family and involved health care workers remain asymptomatic and have been removed from close medical observation," the WHO added.
Rainford today suggested the possibility that none of the other apparent cases in Pakistan will be confirmed by the WHO. "We've got a host of technical issues," he said. "There are practicalities of samples breaking down over time in the transportation."
However, a lack of further confirmations would not change the assumption that person-to-person transmission probably occurred among close contacts, he added. "The clinical evidence is that they did match the case definition of H5N1, so the risk assessment is unchanged."
Rainford said the problems with sample quality could also affect the effort to further characterize the virus through genetic sequencing.
Meanwhile, he said another suspected H5N1 case has been found in the same region of Pakistan as the recent cluster but with no known connection to it. The suspected case is in an 8-year-old who had contact with sick poultry before falling ill, he reported.
"The new case is in the same region, but there's no epidemiologic link to the other cases," Rainford said, adding that he didn't know the specific location.
The WHO's case confirmation came on the same day as the assassination of Pakistan's former prime minister, Benazir Bhutto, which sparked unrest in the country. Rainford said he couldn't speculate about how the assassination and related events might affect Pakistan's response to the H5N1 threat.
"There might be implications for investigations or movement of samples, but I really couldn't say at this point," he said. He said a special WHO team that helped investigate the human cases in Pakistan returned to Geneva "sometime ago."
Today's WHO announcement makes Pakistan the 14th country with confirmed human H5N1 cases. The WHO's global case count has reached 343 cases with 212 deaths.
Meanwhile, Egypt's health ministry reported two more human H5N1 cases in the country today, a day after the WHO confirmed Egypt's 39th case, according to a Reuters report. Amr Kandeel, head of communicable disease control, said the patients were from Damietta and Menoufia and were both hospitalized, the story said.
The state news agency, MENA, identified the Menoufia patient as 22-year-old Nora Aboul Abbas Mohamed but gave no details on the other patient, Reuters reported.
The WHO has not yet recognized the two cases, which would bring Egypt's total to 41, with 16 deaths.
See also:
Dec 27 WHO statement on Pakistan case
http://www.who.int/csr/don/2007_12_27/en/index.html

http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/dec2707pakistan.html
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

niman said:
Commentary at

http://www.recombinomics.com/News/12270709/H5N1_Pakistan_False_Delay.html
Click to expand...
Commentary

False Negatives Delay WHO Update on H5N1 Clusters in Pakistan

Recombinomics Commentary 23:02
December 27, 2007

Dr. Frederick Hayden said confirmatory tests on specimens taken from a number of other members of the family were not positive. But that shouldn't be taken as a sign that they were never infected, he cautioned.

"I think that there's a probability that other individuals in this family were in fact H5N1-infected," said Hayden, adding that blood testing on surviving members of the family holds the key to fleshing out how many infections actually occurred in this cluster.

The negative results may be the product of degradation of specimens that were shipped to a WHO collaborating lab in London for confirmatory testing, Hayden said. Other factors could also have affected the results, including when in the course of infection the specimens were taken or whether suspect cases were started on antiviral drugs before a sample was taken.

A fourth brother was also hospitalized for illness around the same time. He survived. Several other members of the family tested negative for infection, including a brother and his son who live on Long Island, N.Y. They had travelled to Pakistan to attend at least one of the funerals and suffered mild respiratory symptoms on their return to the United States.

The above comments provide updated details on the testing of Pakistan samples by the mobile unit of NAMRU-3 and Mill Hill in London. Most of the initial confirmatory tests were negative, but the negatives are likely to be false because of the patient?s symptoms and earlier positive results by Pakistani labs.

Serum samples from these patients, as well as at least one health care worker, will be tested for H5 antibodies, which can be used to confirm H5N1 infections.

The above comments contradict the report by New York, which stated that the son of the New York resident had not been exposed to H5N1, implying he did not travel to Pakistan. It is not clear if the New York residents will also be tested for H5 antibodies.

The negative data does demonstrate that many factors can produce false negative, including sample degradation and suppression of RNA levels by Tamiflu treatment. The above detail helps explain the delays in the WHO update.

Details on disease onset dates, relationships of confirmed positives, and sequence data would be useful.


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Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

niman said:
Commentary at

http://www.recombinomics.com/News/12280701/H5N1_Pakistan_H2H2H_Confirmed.html
Click to expand...
Commentary

Confirmation of Sustained H5N1 Transmission in Pakistan

Recombinomics Commentary 2:14
December 28, 2007

Citing information from Pakistan's health ministry, John Rainford, a WHO spokesman in Geneva, identified the man as a 25-year-old from the Peshawar area who became ill on Nov 21, was hospitalized Nov 23, and died Nov 28.

"He is the third of four brothers who developed proven or suspected pneumonia with illness onset dates between 29 October and 21 November," Rainford told CIDRAP News. "The brothers provided care for one another and had close personal contact in both the home and hospital."

According to previous reports, the family group was among eight people in Pakistan's North-West Frontier province, near the Afghan border, who were previously diagnosed with avian flu on the basis of preliminary tests in Pakistan. The eight included four brothers and a cousin from the same family, plus three other people. Another brother also had a flu-like illness but died without being tested.

The other patients who tested positive have been described as a man and his niece who were involved in poultry culling, plus a male farm worker.

Although the WHO Pakistan situation update did not contain the critical dates, the above CIDRAP report provides some of the key information to demonstrate sustained human-to-human (H2H) transmission through multiple generations in Pakistan. The above information indicates the index case developed symptoms October 29. Media reports indicate the first fatality died November 19, suggesting his disease onset was well into November. The second fatality developed symptoms November 21, providing an H2H2H transmission chain of index case to first fatality to second fatality. However, there were two other brothers and cousin with symptoms, so the chain may have additional internal links. The above description does not include the two health care workers, who are still questionable.

In addition to the large cluster, the small cluster of a man and his niece may represent another H2H cluster. The above discussion does not include their disease onset dates.

Thus, the above large cluster appears to be represent the most sustained H2H H5N1 transmission chain reported to date, but the sample handling is nothing short of an major disaster. The samples from most of the cases, which were positive cases based on clinical and epidemiological data, have not been lab confirmed by NAMRU-3 or Mill Hill due to sample collection after the start of Tamiflu treatment, sample degradation due multiple tests involving freeze / thaws, packaging and shipping issues, coupled with reporting delays and a lack of transparency.

These false negatives and lack of transparency continue to increase pandemic concerns.


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Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

The negative data does demonstrate that many factors can produce false negative, including sample degradation and suppression of RNA levels by Tamiflu treatment.....
Click to expand...

Can tamiflu-supressed cases still produce antibodies? Will they show up in 21 days in sufficient quantity to test?

.
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

niman said:
Commentary at

http://www.recombinomics.com/News/12280702/H5N1_Pakistan_New_Concerns.html
Click to expand...
Commentary

New Suspect H5N1 Case in Pakistan Increases Concerns

Recombinomics Commentary 2:48
December 28, 2007

another suspected H5N1 case has been found in the same region of Pakistan as the recent cluster but with no known connection to it. The suspected case is in an 8-year-old who had contact with sick poultry before falling ill, he reported.

"The new case is in the same region, but there's no epidemiologic link to the other cases," Rainford said

The above comments describe a new suspect sporadic H5N1 case in Pakistan. The new specifics on the earlier clusters, including some disease onset dates, raise concerns of more efficient transmission of H5N1 in Pakistan. The disease onset dates of the large cluster which began in late October and extended at least through the end of November demonstrated multiple human to human transmissions.

The lack of transparency, delayed reporting, and abysmal collection and handling of samples, raise serious concerns over false negatives. The new case above suggests there are additional cases in the area, which has been thrown into turmoil because of the Benazir Buttoh assassination.

With the human sequencing in doubt, sequences from poultry collected throughout 2006 and 2007 in Pakistan should be released, along with sequences from 2007 isolates in Afghanistan and India.

The sequence hoarding and false negatives increase pandemic concerns and contunue to be hazardous to the world's health.


.
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

niman said:
Commentary at

http://www.recombinomics.com/News/12280703/H5N1_Pakistan_US_Antibodies.html
Click to expand...
Commentary

Antibody Testing for New York Brother in H5N1 Pakistan Cluster?

Recombinomics Commentary 3:59
December 28, 2007

Yet another brother, who lives on Long Island, N.Y., travelled to Pakistan with his son to attend at least one of the funerals. On their return to the United States they suffered mild respiratory symptoms and consulted their family doctor, who alerted New York State public health authorities.

In early December, the U.S. Centers for Disease Control sent a plane to Albany, N.Y., to collect samples taken from the two. Testing at the CDC's labs in Atlanta confirmed the man and his son were not infected with the virus.

The above comments on the son contradict the State of New York report that indicated the family of the brother from New York was not exposed to the cases in Pakistan. If both father and son flew to Pakistan for the funeral(s), there would have been exposure. The first brother died November 19 and the other fatally infected brother developed symptoms November 21, so if the father and son were in Pakistan for the first funeral, they would have been exposed to the second brother, as well as the source that infected the second brother. Moreover, if they then stayed for the second funeral, they would have been in Pakistan for more than 3 weeks, since they returned to New York on December 5.

Pakistan acknowledged that some relatives did not develop pneumonia because they were receiving Tamiflu prior to collection of samples. It seems likely that both father and son from the US would also be receiving Tamiflu. One or both developed respiratory symptoms, but testing of mild cases frequently generates false negatives.

As noted in the recent reports on the WHO updates, most of the confirmatory test on patients that had previously tested positive in Pakistani labs, tested negative in NAMRU-3?s mobile lab as well as the Mill Hill labs in London.

Thus, negative testing of the New York residents does not preclude infections in Pakistan, since their symptoms were mild, and they were likely taking prophylactic Tamiflu when tested in the US.

WHO had indicated that follow-up antibody testing was planned for the relatives in Pakistan. The same testing should be applied to the relatives who returned to the United States.


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Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Here is a list of current suspected and possibly positive human cases associated with outbreaks in Pakistan. This information is based primarily on posts 157 and 160 above, commentaries by Niman, and earlier news posts in this thread.

It summarizes two potential clusters and two isolated cases including one young 8 year old child reported yesterday in post 160. The list also identifies the individuals that I think were the initial nine cases that tested positive in Pakistan. Originally 40 human samples were tested at the end of October/early November. Four were positive and Niman has suggested that all four of these samples were from cullers. If so, the four would mostly likely be Ishtiaq, the veteranarian; one of his brothers who was a culler; the poultry culler from Mansehra (index case for the second cluster); and another culler from Mansehra identified below as Isolated Case #1.

The number of brothers (and the names) in the Durrani cluster is confusing.The index case is fairly well established as Ishtiaq, the verteranarian. Mohammad Ilyas Durrani is almost certainly one of the brothers that died. The names of the remaining brothers, their occupation, and testing results are unclear. Names reported in media, include Tariq, Owais, Farooq, Idrees, and Omar. One of these might be the brother who travelled to Pakistan with his son to attend a funeral of one or both of his brothers.

Further epidemiological information on these individuals would clarify important information about potential human-to-human transmission in Pakistan.

Case listing

Cluster 1

Index Case
Ishtiaq Durrani (Age ?, M)
Occupation: Veterinarian overseeing culling at Ijaz Shah Poultry Farm, Abbottabad District from October 21-23, 2007.
Location of infection: Abbottabad District, Pakistan
Residence: Sukur village near Peshawar, Pakistan (?)
Onset: Oct 29, 2007 (October 25, 2007?)
Status: Recovered
Initial Test Results: Positive (positive 1)
Later Test Results: Positive WHO?
<!--[if !supportLineBreakNewLine]--><!--[endif]-->
Mohammad Ilyas Durrani ? (Age: 20-30, M, Brother 1)
Occupation: Student at agricultural college
Location of Infection: Peshawar?s Khyber Teaching Hospital (KTH)
Residence: Unknown, possibly Sukur village near Peshawar, Pakistan
Onset: Unknown (Prior to November 21, 2007, estimated early November)
Status: Died November 19.
Initial Test Results: Not tested

Mohammad Owais (or Idrees) Durrani (Age: 25, M, Brother 2)
Occupation: Student at agricultural college
Location of Infection: Peshawar?s Khyber Teaching Hospital (KTH)
Residence: Unknown, possibly Sukur village near Peshawar, Pakistan
Onset: November 21, 2007
Hospitalized: November 23, 2007
Status: Died November 28.
Initial Test Results: Positive (positive 2)
Later Test Results: Positive WHO

Mohammed Tariq Durrani (Age ?, M, Brother 3)
Occupation: School teacher ?
Location of Infection: Unknown, most likely Peshawar?s Khyber Teaching Hospital (KTH)
Residence: Sukur village near Peshawar, Pakistan (?)
Onset: Unknown
Status: Recovered
Initial Test Results: Positive? (positive 3)

(Omar or Idrees or Owais or Farooq)? Durrani (Age 38?, M, Brother 4)
Occupation: Culler
Location of Infection: Abbottabad District?
Residence: Unknown
Onset: Unknown
Status: Recovered
Initial Test Results: Positive? (positive 4)

(Omar or Idrees or Owais or Farooq)? Durrani (Age ?, M, Brother 5)
Occupation: Unknown
Location of Infection: Peshawar, Pakistan ?
Residence: Sukur village near Peshawar, Pakistan (?)
Onset: Unknown
Status: Recovered
Initial Test Results: Positive? (positive 5)

(Omar or Idrees or Owais or Farooq)? Durrani (Age 38?, M, Brother 6)
Location of Infection: Peshawar, Pakistan? (assuming infection)
Residence: Nassau County, NY
Status: Healthy (recovered?)
Initial Test Results: Unknown
Later Test Results: Negative
Comments: Reported as 38 years old at http://www.care-mates.com/blog/?p=42

? Durrani child (Age ?, M, Son of Brother 6 and nephew to index case and the other 4 brothers)
Location of Infection: Peshawar, Pakistan? (assuming infection)
Residence: Nassau County, NY
Status: Healthy (recovered?)
Initial Test Results: Unknown
Later Test Results: Negative

Omar? (Age ?, M, cousin of Durrani brothers?, husband of female doctor?)
Occupation: unknown, husband of wife who worked at KTH?
Location of Infection: KTH, Peshawar
Residence: Palosai town, Peshawar, Pakistan
Onset: Unknown
Status: Healthy, recovered?
Initial Test Results: Positive (positive 6)
Unknown (may be the 9th case as reported by WHO on Dec 15, 2007)
Comments: May have been infected through wife at KTH. Wife may be the case reported as female doctor.

Female Doctor (Age:?, F)
Occupation: Doctor at KTH
Location of Infection: Peshawar?s (KTH)?
Residence: Unknown
Onset: Unknown
Status: Healthy, recovered?
Initial Test Results: Positive, but with a non standard test.
Later Test Results: Negative?
Comments: May have been the spouse of the infected individual above who is identified as a possible cousin of the Durrani brothers

Cluster 2

Index Case
Unnamed Individual (Age:? M)
Occupation: Poultry Culler
Location of Infection: Manserha District?
Residence: Unknown
Onset: Unknown (October ?)
Status: Unknown
Initial Test Results: Positive (positive 7)

Unnamed girl (Age:10, F, niece of culler above)
Occupation: Child
Location of Infection: Abbottabad District?
Residence: Unknown
Onset: Unknown
Status: Unknown
Initial Test Results: Positive (positive 8)
Later Test Results: Unknown

Isolated Case #1

Identified as ?another man? (Age:?, M)
Occupation: Poultry culler?
Location of Infection: Manserha District ?
Residence: Unknown
Onset: Unknown (October ?)
Status: Unknown
Initial Test Results: Positive (positive 9?)
Later Test Results: Unknown ?
<!--[if !supportLineBreakNewLine]--><!--[endif]-->
Isolated Case #2

Identified as a Child (Age: 8, M)
Occupation: Poultry culler?
Location of Infection: Unknown
Residence: Unknown
Onset: Unknown (December ?)
Status: Unknown
Initial Test Results: Positive?
Later Test Results: Unknown<o:p></o:p>
<!--[if !supportLineBreakNewLine]-->
<!--[endif]--><o:p></o:p>
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

AlaskaDenise said:
Can tamiflu-supressed cases still produce antibodies? Will they show up in 21 days in sufficient quantity to test?

.
Click to expand...

from: http://www.rxlist.com/cgi/generic/oseltamiv_cp.htm


Immune Response

..... In studies of naturally acquired and experimental influenza, treatment with TAMIFLU did not impair normal humoral antibody response to infection.
Click to expand...
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

mixin said:
Thanks for that link; it's a good one:tiphat:

So does that mean Tamiflu does not create false negatives?
Click to expand...
Tamiflu creates false negatives in PCR tests and limits isolation of the virus for sequencing and otehr studies.
 
Last edited:
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Thank you for the informative case summary Laidback Al!
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

I think I asked about antibody testing when we first heard about the US
brother. I wonder if the public will be informed about antibody testing on him
or will privacy laws be cited as to the reason why we won't be?
Transparency about this case is important. Does he have antibodies
or not? Simple question...
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Blue said:
I think I asked about antibody testing when we first heard about the US
brother. I wonder if the public will be informed about antibody testing on him
or will privacy laws be cited as to the reason why we won't be?
Transparency about this case is important. Does he have antibodies
or not? Simple question...
Click to expand...
There has been no indication that he will be tested for convelescent antibodies.
 
Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

WHO: Flu Burung To Spread Infection Between Humans Occurred in Pakistan

The expert from the Kesehatan Body of the World (WHO) confirmed the first case of bird flu that spread between humans in Pakistan.
However, according to them, this spread was very limited so as to be not risky spread.

The special test that was carried out in the Cairo laboratory and London showed that the person who was infected fatally by the virus H5N1 this did not have the story of contact with the poultry that was infected.

According to WHO, indeed contamination of humankind had to humankind been reported in Cambodia, Indonesia, and Vietnam in several months that. Although, that did not yet spread to more than one person.
Now the case a person suspect bird flu was in China denied by the local government.
In the last case in Pakistan, an official WHO said that the beginning cheque found did not have proof that showed the case spread between humans that continued or gathered.

The experts worried that strain the virus H5N1 has had the mutation became the very cruel form and spread, that could cause the pandemic as that happened the case of the flu pandemic in Spain in 1918,yang was claimed sacrificed 10 million souls.
The WHO team sent results of the research after the Health Minister local announced the death of a man who was one from six people who were infected H5N1 in the North West Frontier Province territory, the Afghanistan border.
Relatives from casualties also died on November 23 before being carried out by the test for the bird flu virus.
Both of them indeed worked in the place that was separated far from the poultry that was infected.
Till at this time, bird flu killed 211 people from 343 people who were infected.
Where the first case was to humankind reported since 2003 that was worried by this virus could mutate headed the form that really was easy to spread among humans.

Because, if this happened, could cause the plague of the world that could kill millions of humankind only in time singkat. Not was different from the annihilator's mass biological weapons.

In the meantime, the Bird Flu Researcher from the Health Faculty of the Airlangga University Animal, CA Nidom, said that indeed had the indication of the virus H5N1 began to change the form resembled was similar to the available virus in humans. Admitted/confessed him, there was the sign- the sign that the virus now no longer spreads through the poultry.

Results of this conclusion were based on his research in many cases of available bird flu in Indonesia.
In the meeting in Bandung around the last two months, the team's findings of this researcher have been sent to the government.

That is that the bird flu virus now has the new identity "humanized virus".
"Now the time for the government to increasingly encourage the control of this virus", he said to SINDO. Nevertheless, he not deny that the source of the spread of bird flu, the poultry still continue to be playing role. Certainly him, in Indonesia indeed a great number were found the poultry in the settlement.
So as rather was difficult to distinguish which virus that really from the poultry, and whatever that not.
"I recommended to the government to more serious open up the virus mystery this. The mechanism of the sending of the sample to WHO indeed stayed important.
However, more important again open up mystery in order to prevent the occurrence of the pandemic or the plague that could kill millions of humankind in time in an instant", he explained.

Responded to the WHO statement about the spread of bird flu between humans that was limited that, according to Nidom, could not be regarded as something that not serious. That was a warning that the bird flu virus currently becomes increasingly strong and vicious. So that the anticipation action and vigilance must be increased.

http://www.seputar-indonesia.com/ed...rung-menular-antarmanusia-terjadi-di-pak.html
 
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