Pakistan: Human H5N1 Cluster December 2007

[AlaskaDenise]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Regarding cousin marriages, see http://www.cousincouples.com/info/facts.shtml

They say the US is the only western country with cousin marriage restrictions.

The high rate of male infections may be due to something as simple as these cullers were working away from home. Since the culling was not a regular day-to-day job, they may have recruited workers from distance communities.

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[AlaskaDenise]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

<TABLE cellSpacing=0 cellPadding=0 width=600 align=center border=0><TBODY><TR bgColor=#f4faff><TD class=heading_txt height=20>WHO team visits families of bird flu victims</TD></TR><TR><TD>

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</TD></TR><TR><TD class=small_txt height=20>By By Mushtaq Yusufzai
12/19/2007</TD></TR><TR><TD class=small_txt>PESHAWAR: A team of the World Health Organisation experts on Tuesday visited the NWFP where they visited the Khyber Teaching Hospital and also met the ill-fated family of two young students who died of bird flu virus in October.

Also, a WHO technical team is also arriving Pakistan today (Wednesday) which, according to sources, would verify the results of bird flu victims diagnosed by the NIH Islamabad.

After their arrival, the WHO officials held talks with senior officials of the NWFP health department who told them of the situation in the province created after the bird flu virus.They went to the Khyber Teaching Hospital (KTH) where the two young brothers, Muhammad Idrees and Muhammad Ilyas, died on October 19 and 29 respectively mainly because of sheer negligence of the hospital administration, the NWFP health department as well as of the National Institute of Health (NIH), Islamabad.

In KTH, the WHO team arranged an informative workshop for doctors and nurses of the hospital, especially those dealing with bird flu patients.

Officials in the KTH told 'The News' the WHO team had brought Personal Protection Equipment (PPE) for the staff of the hospital.

The team also visited isolation rooms in the hospital where patients suffering from bird flu virus were admitted and advised the hospital administration to select some safe place at a distance from the rest of the hospital for keeping the bird flu victims, so that the virus could not spread in the hospital. It is very painful to mention here that in the entire province, there is not even a single isolation room for infectious diseases.

With the consultation of the WHO team, the KTH administration selected a separate portion in the hospital for keeping bird flu patients. There are 11 isolation rooms in the portion, which would accommodate 22 patients.

Acting Chief Executive KTH, Prof Dr Siddiqur Rahman, nominated Dr Mukhtiar Zaman Afridi as the head of a team that would handle bird flu related cases.

The WHO officials praised doctors and health workers of the KTH for their efforts, which the officials felt saved many lives. The team members said in the world so far 60 per cent of the bird flu patients died while the ratio in Pakistan, 35 per cent, was quite encouraging.

The team members later went to Tajabad town in Peshawar and met the family members of two young brothers died of the disease.

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[Laidback Al]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

. . .
The high rate of male infections may be due to something as simple as these cullers were working away from home. Since the culling was not a regular day-to-day job, they may have recruited workers from distance communities.

Yes, that could be true, but how many other cullers were there. At least 40 human samples were processed yet, it seems that the only positive individuals are people that have some kind of familial, genetic relationship with each other.

In Egypt we saw a lot of children and young people infected. In Indonesia we see cases that have only tenuous links to poultry and a high CFR. In Pakistan, we have more males and less severity.

Something different is happening in Pakistan. We need more information and transparency. And we need the sequences.

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

NWFP govt sets up task force to contain bird flu
Staff Report

PESHAWAR: The NWFP government has set up a task force to monitor and contain bird flu or avian influenza in the province, officials said on Saturday.

A Health Department official, requesting anonymity, told Daily Times that a task force had been established at the Chief Minister’s Secretariat to monitor the spread of the diseases.

“At present there are no people in quarantine in the province,” he said and added that two people belonging to Manshera died recently at the Khyber Teaching Hospital (KTH) and three others were also believed to be infected.

“Two people have been discharged while the third one, a KTH doctor, is suspected to be infected and officials are awaiting his test reports from the National Institute of Health (NIH) Islamabad,” he added.

He said there were around 14 centres for the treatment of bird flu in NWFP, with one centre in Mansehra, one in Abbottabad and two in Peshawar.

“We are taking extreme care while treating ordinary flu patients till it is made clear that they are not suffering from the bird flu” he said, and added that World Health Organisation (WHO) experts were also cooperating with them.

NWFP caretaker Health Minister Syed Kamal Shah told Daily Times that so far around six to seven cases of the disease had been reported in the province. He added two of the patients had died in November and that officials were awaiting results of the samples that they had dispatched to the NIH.

“If the results come out to be positive then the samples would be sent to the Centre for Disease Control and Prevention in Atlanta for further confirmation,” he said. “I am trying to get the results but poultry is a big industry with many stakeholders, some of whom may want to hush up the issue.”

“The strain detected in the Bird Flu-infected people is called H5N1, which is the most dangerous of all other strains,” he added.

Shah also said that currently there were three people in the hospitals of Peshawar and Abbottabad. However, he declined to say something about the infected doctor.

He said over 70 percent of the poultry industry was based in NWFP and added that “closure of the industry is under-consideration, as human lives are more precious and important than any industry.”

http://www.dailytimes.com.pk/default.asp?page=2007%5C12%5C18%5Cstory_18-12-2007_pg7_28

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Yes, that could be true, but how many other cullers were there. At least 40 human samples were processed yet, it seems that the only positive individuals are people that have some kind of familial, genetic relationship with each other.

In Egypt we saw a lot of children and young people infected. In Indonesia we see cases that have only tenuous links to poultry and a high CFR. In Pakistan, we have more males and less severity.

Something different is happening in Pakistan. We need more information and transparency. And we need the sequences.

Familial clusters are linked by CONTACT, not genetics.

The genetics are a red herring.

The latest report suggests a MALE HCW is hospitalized. Earlier reports indicated a FEMALE HCW tested positive. It is VERY unlikly that the HCW(s) who were at KTH were related.

They were contacts because of contact, which is how H5N1 is transmitted.

 

[Laidback Al]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Familial clusters are linked by CONTACT, not genetics. . . .

Yes, I would agree in regards to the source of infection in these cases. But don't you think that suspectibility among individuals varies and may possibly be related to genetics?

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Yes, I would agree in regards to the source of infection in these cases. But don't you think that suspectibility among individuals varies and may possibly be related to genetics?

No. Not at this level. This is an AVIAN virus and the genetic composition of infected humans is VERY diverse (as is the dogs, cats, tigers, leopards, pigs, minks, foxes, stone martins, civet cats infected).

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Commentary at

http://www.recombinomics.com/News/12190702/H5N1_Pakistan_HCW_2.html

 

[AlaskaDenise]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Commentary at

http://www.recombinomics.com/News/12190702/H5N1_Pakistan_HCW_2.html

Commentary

Hospitalized Doctor Raises Pandemic Concerns in Pakistan

Recombinomics Commentary
December 19, 2007

?Two people have been discharged while the third one, a KTH doctor, is suspected to be infected and officials are awaiting his test reports from the National Institute of Health (NIH) Islamabad,? he added.

The above comments describe a male health care worker hospitalized at Khyber Teaching Hospital (KTH). Earlier media reports described a female health care worker who had tested positive for H5N1. It is not clear if these two reports refer to the same health care worker, or if there are two who are either lab confirmed or hospitalized. Earlier media reports indicated the lab positive health care worker was not hospitalized.

A hospitalized health care work at this time is cause for concern. Although no official onset dates have been released, the consensus in media reports indicates the index case for the larger familial cluster was a veterinarian who organized a cull October 21-23. He developed symptoms on October 25 and was hospitalized at KTH. Two of his brothers, who were students and were not involved in the cull, visited him at the hospital and were subsequently hospitalized there. These two brothers died November 19 and 29. One was tested and was H5N1 positive as were two other brothers and a cousin. The above comments suggest at least one of the surviving relatives was also hospitalized at KTH.

If the above health care work is H5N1 confirmed, a long transmission chain is likely, based on the disease onset date of the index cases on October 25 and the dates of the deaths of the two brothers, November 19 and 29.

Disease onset dates and contact dates are required to detail the chain, but a chain for almost two months would be an H5N1 record and increase pandemic concerns.

Details, including disease onset dates and confirming lab tests, as well as sequence data, would be useful.


.

 

[hawkeye]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

I've updated the map to include the location of the KTH doctor.

 

[Shannon Bennett]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Are there cultural differences in who cares for the sick in Pakistan? Are males the only/primary persons who visit hospitals? Mens and womans quarters are separate in most Pakistani households, especially in wealthier homes. Since this man was a professional I think we can assume the home was split into gender separation. If that was the case then perhaps the brothers cared for the ill man and not the females in the house.

 

[Laidback Al]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Are there cultural differences in who cares for the sick in Pakistan? Are males the only/primary persons who visit hospitals? Mens and womans quarters are separate in most Pakistani households, especially in wealthier homes. Since this man was a professional I think we can assume the home was split into gender separation. If that was the case then perhaps the brothers cared for the ill man and not the females in the house.

The news report indicate that it was the two student brothers who attended to the veterinarian, Ishtiaq, while he was being treated in the hospital. Why did the veterinarian, the index case, survive while the other two brothers who must have exhibited symptoms (in or near the hospital) did not?

Speculation -

Is it possible that the veterinarian had some previous exposure and had some limited immunity? Or did he just receive better care or antivirals earlier?

 

[Shannon Bennett]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

But who treated him at home before going to the hospital? The brothers or, his presumed wife/mother/sister?

Good question why did he survive?

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

No bird flu threat in Pakistan
'Pakistan Times' Wire Service
ISLAMABAD: Pakistan said on Wednesday there was no threat of a pandemic from bird flu, as World Health Organisation experts visited the country's northwest which reported the first human death from the virus.
Pakistani authorities confirmed at the weekend eight human bird flu cases, including the one death, that the WHO said were likely a combination of infections from poultry and limited person to person transmission due to close contact.
"There is no threat of epidemic or pandemic and there are no fresh cases being reported," Ministry of Health spokesman Orya Maqbool Jan Abbasi was quoted as saying. The last human case was reported on November 23.
"I think we are safe, but we are very cautions and have taken all the precautionary measures." A WHO report is due in the coming days, Abbasi said.
A report from Beijing quoting World Health Organization (WHO) said Tuesday the cases of H5N1 avian influenza among people in Pakistan have risen to eight.
WHO spokesman Greg Hartl gave the confirmation about the first such cases in Pakistan's remote North-West Frontier province through a telephone interview.
He detailed that one patient died, six recovered and one remained under medical supervision in the cities of Abbotabad and Mansehra.
The eight cases have a combination of infections from poultry and limited person-to-person transmission from close contact, according to Keiji Fukuda, coordinator of WHO's global influenza program.
"Right now it doesn't look like pure human to human transmission. It looks like the veterinarian, who was the index case, and a number of other suspect cases had poultry exposure," Fukuda said in an interview.
"It is definitely possible that we have a mixed scenario where we have poultry to human infection and possible human to human transmission within a family, which is not yet verified."
But human-to-human transmission "would not be particularly surprising or unprecedented," he added.
Pakistani and WHO officials said there was no immediate cause for alarm and the United Nations agency was not raising its level of pandemic alert for the time being.
Fukuda said it was very reassuring that "we are not seeing large increases in the number of cases."
But some public health officials worry that should the virus gain the ability to transmit easily among humans, a pandemic could occur.
Hartl said, "Our concern is that once this virus remains in the animal population, it mutates into a more transmissible form.
And the more they (the viruses) stay in the animal population, then we have a panic situation."
The WHO Tuesday noted the death of Indonesia's latest avian flu patient, a 47-year-old man from Tangerang who died Dec 13.
The country's overall H5N1 count has reached 115 cases with 93 deaths. Since 2003, the health agency has tallied 341 cases among people in 14 countries and regions, 210 of them fatal.

http://www.pakistantimes.net/2007/12/19/top12.htm

 

[cartski]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Since we're into the realm of speculation, why not delve into what might have happened while caring for an ill patient in a Pakistan hospital.

I do not know the norm in Pakistan hospitals, but I do know that in China hospitals the family members are the nurses. Is it similar? What role did the brothers play in the care of the patient?

The two brothers could have been charged with cleaning up vomit or incontenance. A simple, messy clean up could have exposed them to an overwhelming viral load, even if they weren't genetically related. Frankly, we need much more detailed information about the care of the index case.

I admit being frustrated with the rampant use of "H2H" in these situations.

"H2H" is such an ill-defined term in all these news reports and commentaries. If it is the WHO's phase 3 definition that we're concerned about: [ "phase 3: a new influenza virus subtype is causing disease in humans, but is not yet spreading efficiently and sustainably among humans" ] surely the contact with large quantities of shedding material is insufficient to meet this definition.

"Casual contact" H2H, as mentioned yesterday in a report, would be very alarming. How can being immersed large amounts of viral material, which may plausible in this hospital envrionment, qualify?

J.

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Since we're into the realm of speculation, why not delve into what might have happened while caring for an ill patient in a Pakistan hospital.

I do not know the norm in Pakistan hospitals, but I do know that in China hospitals the family members are the nurses. Is it similar? What role did the brothers play in the care of the patient?

The two brothers could have been charged with cleaning up vomit or incontenance. A simple, messy clean up could have exposed them to an overwhelming viral load, even if they weren't genetically related. Frankly, we need much more detailed information about the care of the index case.

I admit being frustrated with the rampant use of "H2H" in these situations.

"H2H" is such an ill-defined term in all these news reports and commentaries. If it is the WHO's phase 3 definition that we're concerned about: [ "phase 3: a new influenza virus subtype is causing disease in humans, but is not yet spreading efficiently and sustainably among humans" ] surely the contact with large quantities of shedding material is insufficient to meet this definition.

"Casual contact" H2H, as mentioned yesterday in a report, would be very alarming. How can being immersed large amounts of viral material, which may plausible in this hospital envrionment, qualify?

J.

Spreading "efficiently and sustainably" used to be PHASE 6.

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

WHO team begins investigating bird flu outbreak
ISLAMABAD: A WHO team began investigating Pakistan?s first human bird flu cases on Tuesday to try to determine whether human-to-human transmission may have occurred. The health experts visited a hospital in Peshawar that had treated most of the eight patients suspected of being infected with the H5N1 virus, said Gregory Hartl, a WHO spokesman. One of the survivors said he had exhibited flu symptoms after slaughtering chickens without wearing protective clothing. His deceased siblings had visited him, reported AP. Health Secretary Khushnood Lashari said the man who had been culling poultry might have inadvertently brought the virus to his home, where the brothers fell sick, through his equipment. Separately, WHO?s global influenza programme coordinator Keiji Fukuda said the suspected human bird flu cases in Pakistan are likely a combination of infections from poultry and limited human-to-human transmission. He said there was no need for alarm, adding that WHO was not raising its level of pandemic alert for the time being, reported Reuters. agencies

http://www.pakistanlink.com/Headlines/Dec07/19/10.htm

 

[Theresa42]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Yes, I would agree in regards to the source of infection in these cases. But don't you think that suspectibility among individuals varies and may possibly be related to genetics?

No. Not at this level. This is an AVIAN virus and the genetic composition of infected humans is VERY diverse (as is the dogs, cats, tigers, leopards, pigs, minks, foxes, stone martins, civet cats infected).

Perhaps the different genetics of different people (e.g. families) affects not the susceptibility to being infected, but the severity of the infection? How one's system reacts to the infection? Then we see a bunch of brothers in Pakistan who's systems don't handle the infection (or handle the infection too well maybe!) whereas some other people around them don't get such severe infections? I dunno -- just speculating.

Obviously antibody studies of all the contacts of this family would help clarify.

 

[HenryN]

Re: Pakistan: December 18+, WHO Begins Investigations

Re: Pakistan: December 18+, WHO Begins Investigations

Commentary at

http://www.recombinomics.com/News/12190703/H5N1_Pakistan_H2H_Specifics.html

 

[HenryN]

Re: H2H suspected in Pakistan?

Re: H2H suspected in Pakistan?

<TABLE cellSpacing=1 cellPadding=1 width="100%" border=0><TBODY><TR><TD>WHO says Pakistan bird flu cluster no cause for alarm as yet

</TD></TR><TR><TD class=article-author>Disease/Infection News</TD></TR><TR><TD class=article-date>Published: Wednesday, 19-Dec-2007 </TD></TR><TR><TD><!-- Printer Friendly / Email to a Friend Links --><TABLE cellSpacing=0 cellPadding=0 align=right border=0><TBODY><TR><TD width=15>

</TD><TD> Printer Friendly</TD><TD> </TD><TD width=18>

</TD><TD> Email to a Friend
</TD></TR></TBODY></TABLE></TD></TR><TR><TD><TABLE cellSpacing=1 cellPadding=2 width="100%" border=0><TBODY><TR><TD style="BACKGROUND: url(aspvirtualnews/template_images/smalldot.gif)" height=25> </TD></TR><TR><TD>According to an expert at the World Health Organization, the cluster of suspected bird flu cases in Pakistan may be a combination of infections from poultry with limited person-to-person transmission.

In the cluster, eight people in North West Frontier Province, Pakistan's "poultry belt", have tested positive for the H5N1 bird flu virus since late October; of the confirmed cases one man has died along with his brother who was never tested and is not included in the tally.
Six have recovered and one remains under medical supervision in the cities of Abbotabad and Mansehra.
The WHO says though this is Pakistan's first outbreak of bird flu among people, several outbreaks of H5N1 influenza have occurred among poultry and spread to the country's wild birds earlier this year.
Keiji Fukuda, the coordinator of WHO's global influenza program, says though still unconfirmed, it appears that any human-to-human spread was the result of close contact by family caring for sick loved ones as in previous outbreaks in Thailand and Indonesia.
The cases initially caused alarm as there has always been the very real fear that the H5N1 bird flu virus will ultimately mutate and acquire the ability to pass from person to person causing a pandemic.
Almost all human cases of bird flu to date have been the result of close contact with infected birds.
The WHO however says there is no immediate cause for alarm and they are not raising the level of pandemic alert as the cases do not appear to be the result of just human to human transmission.
It seems a veterinarian, who was at the centre of the outbreaks and a number of other suspect cases were exposed to poultry.
The veterinarian assisted with culling operations, became infected but did recover whereas his two brothers who cared for him also became infected and died.
Fukuda says it is quite possible that there was a mixed scenario where poultry to human infection occurred and then possibly human to human transmission within a family.
While this has not as yet been verified experts say human to human transmission would not be particularly surprising or unprecedented.
The H5N1 strain of bird flu remains a disease of animals, but any mutation enabling the deadly virus to pass between humans could trigger a pandemic which could kill millions of people.
So far the largest known cluster of human bird flu cases worldwide was in May 2006 in Indonesia's North Sumatra province, where as many as seven people in an extended family died.
The WHO has dispatched three experts, led by Hassan El-Bushra from it's Cairo office, to help Pakistan investigate the outbreak.
The WHO has a set of six phases of pandemic alert which gauges the level of threat and the world is currently in phase 3, which indicates a new influenza virus subtype which is causing disease in humans, but is not yet spreading efficiently or sustainable among humans.
In terms of public health implications, the WHO are watching for human to human transmission where casual contact leads to infections and fosters large outbreaks in communities.
The U.S. Naval Medical Research Unit NAMRU-3 laboratory from Cairo is now in Pakistan and will conduct further tests on the samples from the suspected cases.
According to the WHO since 2003 there have been 341 cases among people in 14 countries, and 210 of them were fatal.

http://www.news-medical.net/print_article.asp?id=33693
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