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Pakistan: Human H5N1 Cluster December 2007

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

These are no longer open issues. Neither visitor fromn the US tested positive in Pakistan or the US.

Do you know something or do I detect sarcasm in your "voice"?:cool:
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Wasn't the individual quarantined in the plane? What about the others on the plane. Of course this is a non-issue now that the individual tested negative, but they did not know that at the time.

Is Jason's post the only one that mentions 2 US residents? As per the New York state official, this returnee(s)? returned and the one who was sick(?) went to his family doctor. There are so many versions here.

My source indicated that the suspected H5N1 individual was placed in medical isolation at some point - not just a doctor's visit. And he tested negative for H5N1. It was never indicated to me that this person was one of two that had gone on that trip, but my source did not have all the details since this was not his work area.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

The most important thing will be unravelled by NAMRU-3 analysis: whether or not H5N1 has mutated. Until these results are available, any consideration about this incident will remain speculative.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

My guy told me what he heard. This plane situation appears to be murky at this point.

I repeat, a press release with details would be nice.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Bloomberg report is updated.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Pakistan Has Eight Suspected Human Cases of Bird Flu (Update2)

By Jason Gale

Dec. 16 (Bloomberg) -- Five members of a family in Pakistan are among eight people who may be the country's first human cases of bird flu, the World Health Organization said. At least one brother died.

Pakistan's national laboratory found the lethal H5N1 avian flu strain caused the infections in three brothers and two cousins from the same family, according to information from a WHO statement today and Gregory Hartl, a WHO spokesman in Geneva. Another brother and his son from the U.S., who attended a funeral for one of the victims, tested negative for the virus at a hospital in Nassau County, New York, Hartl said.

Medical teams have been sent to Pakistan to assist local authorities in investigating the cases, in which two people had only mild symptoms, Hartl said. Avian flu has infected at least one person a month in Asia and Africa during the past three years, and doctors are monitoring for signs it may be adapting to humans by killing fewer people, fostering its spread.

``It's too early to make any definitive conclusions'' about the outbreak, Hartl said in a telephone interview today. ``We are still in the middle of it.''

Voluntary Isolation

New York State health officials were informed Dec. 7 that a man from Nassau County had returned from Pakistan with flu symptoms, said Claudia Hutton, director of public affairs for the state department of health. The man told his doctor he might have been exposed to bird flu, Hutton said in telephone interview.

The man went into voluntary isolation at home, Hutton said. Then his son began developing flu-like symptoms. Samples from both the man and his son were tested at state laboratories and at the U.S. Centers for Disease Control and Prevention in Atlanta.

The samples came back negative for H5N1 bird flu earlier this week, and the man and his son are no longer in isolation, Hutton said.

``The man did a courteous thing by seeing his physician and saying `I might have been exposed,''' Hutton said. ``In the end, no one in New York is sick.''

Hutton said she didn't know whether the man or his son received antiviral medications. Drugs such as Roche Holding AG's Tamiflu are believed to fight bird flu.

Pakistan Teams

Hutton said that there were erroneous reports on the Internet that another brother of the H5N1-infected family members in Pakistan has returned to the U.S. and tested positive.

``That's not true,'' she said. ``At this point there's no risk to the public or the individuals.''

CDC officials referred all questions to the New York State health department.

The remaining suspected cases in Pakistan include a man and his niece, and a male who worked on a farm about 12 miles (20 kilometers) away.

Doctors from WHO in Geneva and Cairo, and from the U.S. Navy Medical Research Unit No. 3 in Cairo will arrive in Pakistan during the next two days to track and stem the disease's spread, and to analyze specimens for any genetic mutations in the virus.

340 Human Cases

Pakistan has reported 44 H5N1 outbreaks in poultry to the World Organization for Animal Health since early 2006. The most recent occurred on Nov. 27 and Nov. 28 in the states of Punjab and North-West Frontier Province, killing almost 20,000 chickens.

The suspected Pakistan cases occurred in the Peshawar area of the country and were detected following a series of culling operations in response to outbreaks of H5N1 in poultry, according to the WHO statement. Samples from the cases are being sent to a WHO reference laboratory in Cairo for confirmation and further analysis.

At least 340 people in 13 countries have contracted the virus since 2003, WHO said yesterday. Three of every five cases were fatal and most were caused by contact with infected poultry, such as children playing with them or adults butchering them or plucking feathers, according to the Geneva-based agency. It says millions could die if the virus becomes as contagious as seasonal flu and touches off a global pandemic.

To contact the reporter on this story: Jason Gale in Singapore at j.gale@bloomberg.net
Last Updated: December 15, 2007 16:34 EST

http://www.bloomberg.com/apps/news?pid=20601080&sid=augrVjqpgRrQ&refer=asia
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

I would like to make a personal observation. Isn't it interesting how a comment by a foreign health minister/officer about a U.S. resident's health status can be taken as absolute truth? And couldn't this ability and position be used to influence?

We have seen the negative economic effects of H5N1 upon areas with active infection. Here is the FT economic forum that has many articles/items about this.

Just pondering the power of communication and how it can be used against opponents.

In this era of internet rapid pace information, today's rumour can be tomorrow's ruination.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

I would like to make a personal observation. Isn't it interesting how a comment by a foreign health minister/officer about a U.S. resident's health status can be taken as absolute truth? And couldn't this ability and position be used to influence?

We have seen the negative economic effects of H5N1 upon areas with active infection. Here is the FT economic forum that has many articles/items about this.

Just pondering the power of communication and how it can be used against opponents.

In this era of internet rapid pace information, today's rumour can be tomorrow's ruination.
I think PT Barum also weighed in on this one.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

The most important thing will be unravelled by NAMRU-3 analysis: whether or not H5N1 has mutated. Until these results are available, any consideration about this incident will remain speculative.
I can assure you, without seeing any sequence data, that NAMRU-3 will NOT be able to say anything definitive on the sequence data (and there will be NO reassortment).
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

<TABLE cellSpacing=0 cellPadding=0 width="96%" align=center border=0><TBODY><TR bgColor=#f4faff><TD class=heading_txt height=20>Three more bird flu victims detected in NWFP</TD></TR><TR><TD>
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</TD></TR><!-- <tr> <td class="small_txt" height="20">Updated at </td> </tr>--><TR><TD class=small_txt>NIH confirms two patients suffering from H5N1; Federal Health Ministry taking steps to control virus

By Mushtaq Yusufzai

PESHAWAR: The NWFP Health Department on Saturday feared that the bird-flu pandemic could engulf the whole province as three more victims of the virus were admitted to hospitals in Peshawar and Abbottabad.

?The virus can spread to the whole province if precautionary measures are not taken on war-footing by the federal government and the concerned international donors,? remarked NWFP Caretaker Health Minister Syed Kamal Shah.

Also, heirs of two young students and Pakistan?s first-ever bird flu victims held the authorities concerned responsible for their loss.

Official sources told ?The News? that three more patients suffering from bird-flu virus were brought to hospitals in the NWFP.

Two patients ? a 10-year-old girl and a man ? living in the vicinity of a poultry farm in Abbottabad were admitted to hospitals in Abbottabad district on Saturday.

Health Minister Kamal Shah said one of the patients was admitted to the Ayub Medical Complex (HMC) and another to a private health facility, Shahina Jamil Hospital.

Sources told this scribe that blood samples of both the patients were sent to the National Institute of Health (NIH), which confirmed the two patients were suffering from H5N1 virus, which is considered the most severe bird-flu virus.

Also, blood samples of the third patient who was admitted to Peshawar?s Khyber Teaching Hospital (KTH) were sent to NIH, which is supposed to release report within 24 hours.

Two young brothers ? Muhammad Idrees and Muhammad Ilyas ? had lost their lives in the KTH, mainly because of the negligence of the hospital administration as well as lack of coordination between the provincial and federal health departments.

Health Minister Kamal Shah said he did not want to hide the facts from the people and felt the situation could become critical if necessary measures were not taken in time by the federal government as well as by the international donor agencies.

?This is a totally new challenge, which we are completely ill-equipped and ill-planned to tackle,? explained the minister.

He said since it had been confirmed now that the two brothers died in Peshawar were the victims of bird-flu virus, the NIH officials still did not send their report to his ministry. He said if the NIH released its report positive, then they would send it to the Communicable Disease Centre (CDC) in Atlanta, America, for further verification. ?For me, the lives of our people are more important than the poultry industry,? he remarked.

Senior officials of provincial health department said people in the poultry industry were powerful enough to manipulate the bosses of the NIH from releasing its report of the deadly disease that took precious lives and posed serious threat to many others.

The two patients admitted in Abbottabad were reportedly living in the vicinity of a poultry farm.

Similarly, the third patient in Peshawar belonging to the nearby Palosai town was serving as attendant of his wife in KTH when the two brothers were admitted there. Doctors in the KTH said the man was sleeping during the night near the isolation room where the two brothers were kept. He was suffering from severe pneumonia when brought to hospital and was shifted to an isolation room.

Dr Mukhtiar Zaman Afridi, who is a noted chest physician and the head of Pulmonology Department at KTH, has closely observed the five brothers hailing from Charsadda, two of whom later lost their lives due to lethal virus.

The doctors close to Dr Mukhtiar told The News that on the right time he had observed that the two young brothers were not common patients and suggested that there should be special care and treatment for them but as always his cry fell on deaf ears.

The KTH administration did nothing to save the lives of the two seriously- ill patients. ?They did not even inform officials of the provincial health department or NIH to come and collect blood samples of the patients who were fighting between life and death,? said the doctors.

Doctors felt Dr Mukhtiar Zaman?s timely suspicion of the disease and referring the victims of bird-flu virus to isolation ward saved around 75 lives, including doctors and paramedical workers as well as patients admitted in his chest ward.

APP adds: The National Institute of Health in collaboration with the Ministry of Food, Agriculture and Livestock, the Health Department of NWFP, WHO and UNICEF are taking necessary action to control Avian Influenza outbreak in the NWFP.

The National Institute of Health has tested patients and contacts suspected for Avian Influenza in late October, 2007. Six cases were found positive for H5N1 Avian Influenza virus, five of them from Abbottabad and one from Mansehra district.

Five of them have fully recovered, one of the confirmed cases died in hospital while his brother who could not be tested has also died.

To avert the potential spread of this infection to humans, the Ministry of Health has implemented the control activities.:tiphat:
http://www.thenews.com.pk/top_story_detail.asp?Id=11764</TD></TR></TBODY></TABLE>
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

I talked to Jason. He was up late processing this story last night in his time zone. The following is what he told me. There were 2 persons who went to the funeral from the US and then returned. After returning, one person went to his family doctor for consultation. This person volunteered the information of where he had been and the H5N1 scenario. *****

I surmise that the doctor called the local health department.

H5N1 is a reportable disease in the US:

"A human case of infection with an influenza A virus subtype that is different from currently circulating human influenza H1 and H3 viruses. Novel subtypes include, but are not limited to, H2, H5, H7, and H9 subtypes. Influenza H1 and H3 subtypes originating from a non-human species or from genetic reassortment between animal and human viruses are also novel subtypes. Novel subtypes will be detected with methods available for detection of currently circulating human influenza viruses at state public health laboratories (e.g., real-time reverse transcriptase polymerase chain reaction [RT-PCR]). Non-human influenza viruses include avian subtypes (e.g., H5, H7, or H9 viruses), swine and other mammalian subtypes. Confirmation that an influenza A virus represents a novel virus will be performed by CDC’s influenza laboratory.
Criteria for epidemiologic linkage: a) the patient has had contact with one or more persons who either have or had the disease and b) transmission of the agent by the usual modes of transmission is plausible. A case may be considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission is laboratory confirmed."

http://www.flutrackers.com/forum/showthread.php?t=45214

A detailed press release would be nice.

***** Please see comments in the post below.

A detailed press release would be nice.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

i understand from Jason that he doesn't know whether the U.S.-based brother attended the funeral in Pakistan wth or without his son. He's not sure, but suspects he went alone. He heard that he and his son did present to the hospital in Nassau county for testing. kenny
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Thank you F1 and Kenny for making this contact. :)

Thanks to treyfish for that last article. Although laced with political posturing, many new details are offered which help to flesh out the picture.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

<table align="center" border="0" cellpadding="0" cellspacing="0" width="96%"><tbody><tr bgcolor="#f4faff"><td class="small_txt" height="20"> District govts asked to adopt measures against bird flu</td> </tr> <tr> <td>
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</td> </tr> <tr> <td bgcolor="#efefef">
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</td> </tr> <tr> <td class="small_txt"> Sunday, December 16, 2007
ISLAMABAD: The Ministry of Health has advised the provincial and district governments to adopt recommended measures for preventing any outbreak of avian influenza.

The directions have been issued in the wake of high transmission season and the global threat posed by H5N1 influenza virus, sources said.

They added the Ministry of Health had already adopted special preventive measures on the outbreak of influenza in the NWFP poultry farms. The viral transport medium required for the transport of suspected human samples along with related guidelines have been dispatched to the provinces and the district health departments, the sources added.

According to the sources, the government was also considering registration of poultry farms for having proper monitoring system to check any outbreak of bird flu in the country.

According to health experts, the virus may spread from one farm to another and even to population by mechanical means like contaminated equipment, vehicles, feed, bird-cages, etc. They added the fatality rate of disease stood at 70 per cent, which was very high.

http://www.thenews.com.pk/daily_detail.asp?id=86529

</td></tr></tbody></table>
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

<TABLE id=AutoNumber21 style="BORDER-COLLAPSE: collapse" borderColor=#111111 cellSpacing=0 cellPadding=0 width="98%" border=0><TBODY><TR><TD width="100%" colSpan=3>Avian influenza preventive measures adopted
ISLAMABAD: The Ministry of Health has adopted special preventive measures on the outbreak of influenza in NWFP, official sources said.
The viral transport medium required for the transport of suspected human samples along with related guidelines have been dispatched to the provinces and district health departments, sources added.
The directions have been issued in the wake of high transmission season and the global threat posed by H5N1 Influenza virus.
Meanwhile, the Ministry has advised the provincial and district Governments to adopt recommended measures for preventing and averting any outbreak of avian influenza.
According to sources, the government was also considering registration of poultry farms for having proper monitoring system to check any outbreak of bird flu in the country.
As many as 14 suspected patients were admitted last year in hospitals of Lahore and Islamabad however their blood samples were declared negative by the laboratories.
Total 136 blood samples were sent to laboratory for test and all were found negative.
Total 21 cases were reported in poultry farms last year while 76 in 2005 mainly in wild birds and commercial backyard poultry in the country.
Globally 206 deaths have been confirmed due to bird flu in 12 countries out of 335 suspected cases.
According to health experts the virus may expand from one farm to another and even to population by mechanical means like contaminated equipment, vehicles, feed, bird-cages etc.
They added the fatality rate of disease stands at 70% which is very high.
The symptoms of disease included high fever, cough, aches, running nose and sore throat while pneumonia or other complications may occur at a later stage. - APP
</TD></TR><TR><TD width="90%"> </TD></TR></TBODY></TABLE>:tiphat: http://statesman.com.pk/national/national2.htm
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Steps being taken to control Avian Influenza

Islamabad?The National Institute of Health in collaboration with the Ministry of Food, Agriculture and Livestock, the Health Department of NWFP, WHO and UNICEF are taking necessary action to control Avian Influenza out break in NWFP.
The Ministry of Health will maintain this measure to ensure the health and well-being of the population and avert the threat from avian influenza in Pakistan, said a press release issued here on Saturday.
The National Institute of Health has tested patients and contacts suspected for Avian Influenza in late October, 2007. Six cases were found positive for H5N1 Avian Influenza virus, five of them from Abbottabad and one from Mansehra district.
Five of them have fully recovered, one of the confirmed cases died in hospital while his brother who could not be tested has also died.
To avert the potential spread of this infection to humans, the Ministry of Health has implemented the following control activities.
Investigation and sampling of cases and contacts and the organization of active surveillance for the early detection of infection; Ensuring standard treatment to all detected cases and contacts; Identification of isolation wards/rooms in all referral hospitals in the area and the nomination of focal persons to ensure proper case management and early notification of suspected cases; Ensuring an early stock piling of Personal Protective Equipment (PPE), to ensure necessary protection of health providers; Ensuring a preliminary stock of Osaltamivir for prophylaxis and treatment.?APP:tiphat: http://pakobserver.net/news/islamabad07.asp
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Last Updated: December 15, 2007 21:11 EST

Pakistan Has Eight Suspected Human Cases of Bird Flu (Update4)
By Jason Gale


<!-- WARNING: #foreach: $wnstory.ATTS: null at /bb/data/web/templates/webmacro_en/20601080.wm:313.2 --><!-- WARNING: #foreach: $wnstory.ATTS: null at /bb/data/web/templates/webmacro_en/20601080.wm:327.19 --> Dec. 16 (Bloomberg) -- Five members of a family in Pakistan are among eight people who may be the country's first human cases of bird flu, the World Health Organization said. At least one brother died.

Pakistan's national laboratory found the lethal H5N1 avian flu strain caused the infections in three brothers and two cousins from the same family, according to information from a Dec. 15 WHO statement and Gregory Hartl, a WHO spokesman in Geneva. Another brother from the U.S., who attended a funeral for one of the victims, and his son tested negative for the virus at a hospital in Nassau County, New York, Hartl said.

Medical teams have been sent to Pakistan to assist local authorities in investigating the cases, in which two people had only mild symptoms, Hartl said. Doctors are monitoring for signs avian flu may be adapting to humans by killing fewer people, fostering its spread.

``It's too early to make any definitive conclusions'' about the outbreak, Hartl said in a Dec. 15 telephone interview. ``We are still in the middle of it.''

New York State health officials were informed Dec. 7 that a man from Nassau County who had returned from Pakistan told his doctor he might have been exposed to avian flu, said Claudia Hutton, director of public affairs for the state department of health in a telephone interview.


Voluntary Quarantine

The man went into voluntary quarantine at home, Hutton said. Then his son began developing flu-like symptoms. Samples from both the man and his son were tested at state laboratories and at the U.S. Centers for Disease Control and Prevention in Atlanta. The CDC sent an airplane to Albany to pick up the samples, Hutton said.

The samples came back negative for H5N1 avian flu earlier this week, and the man and his son are no longer in quarantine, Hutton said.

``The man did a courteous thing by seeing his physician and saying `I might have been exposed,''' Hutton said. ``In the end, no one in New York is sick.''

Hutton said she didn't know whether the man or his son received antiviral medications. Drugs such as Roche Holding AG's Tamiflu are believed to fight avian flu.

Hutton said that there were erroneous reports on the Internet that another brother of the H5N1-infected family members in Pakistan has returned to the U.S. and tested positive.


`No Risk'

``That's not true,'' she said. ``At this point there's no risk to the public or the individuals.''

CDC officials referred all questions to the New York State health department.

The remaining suspected cases in Pakistan include a man and his niece, and a male who worked on a nearby farm.

Doctors from the WHO in Geneva and Cairo, and from the U.S. Navy Medical Research Unit No. 3 in Cairo will arrive in Pakistan during the next two days to track and stem the disease's spread, and to analyze specimens for any genetic mutations in the virus.

Pakistan has reported 44 H5N1 outbreaks in poultry to the World Organization for Animal Health since early 2006. The most recent occurred on Nov. 27 and Nov. 28 in Punjab and North-West Frontier Province, killing almost 20,000 chickens.

The frequent outbreaks in Pakistan and high density of people meant that it was ``not surprising'' that human cases eventually occurred in that country, Hartl said.


Chickens, Quails

It is too early to determine whether the cases were caused by an animal source or through limited person-to-person spread, he said. Some of the infected people also kept chickens and quails and it is unclear what personal protective equipment was used during culling operations, Hartl said.

Pakistan authorities sent Tamiflu to the affected area to treat cases and prevent further infection, Hartl said.

``Pakistan has been doing everything right'' in terms of tracing people at risk of infection and preventing its spread, Hartl said.

The infections probably began late October in an agriculture ministry official involved in culling diseased poultry on a farm at Abbottabad in North-West Frontier Province, which borders Afghanistan, Hartl said.

The man fell ill and was cared for by two of his brothers, who also became unwell. One of the brothers died about a month ago and was buried before specimens could be taken for a diagnosis. The other died on Nov. 29 and was positive for H5N1 in preliminary tests, Hartl said. Antibody screening on the first man, who recovered, found he'd been infected with H5N1.


U.S. Brother

A third brother was hospitalized for H5N1 infection and also recovered. A fourth brother who lives in the U.S. tested negative for H5N1 after returning to Pakistan for his brother's funeral, Hartl said.

Two cousins, at least one of who is a woman, were positive for H5N1, although they developed only mild symptoms, he said. A man and his niece, who were also involved in culling poultry on either the same or a neighboring farm, have tested positive, Hartl said. The eighth case is a male farm-worker from Mansehra, about 20 kilometers (12 miles) from the other cases, he said.

The suspected Pakistan cases occurred in the Peshawar area of the country and were detected following a series of culling operations in response to outbreaks of H5N1 in poultry, according to the WHO statement. Samples from the cases are being sent to a WHO reference laboratory in Cairo for confirmation and further analysis.

Avian flu has infected at least one person a month in Asia and Africa during the past three years.

At least 340 people in 13 countries have contracted the virus since 2003, WHO said Dec. 14. Three of every five cases were fatal and most were caused by contact with infected poultry, such as children playing with them or adults butchering them or plucking feathers, according to the Geneva-based agency. It says millions could die if the virus becomes as contagious as seasonal flu and touches off a global pandemic.


To contact the reporter on this story: Jason Gale in Singapore at j.gale@bloomberg.net

http://www.bloomberg.com/apps/news?pid=20601087&sid=aVTc75sr5yCM&refer=home




 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

The National Institute of Health has tested patients and contacts suspected for Avian Influenza in late October, 2007. Six cases were found positive for H5N1 Avian Influenza virus, five of them from Abbottabad and one from Mansehra district.

Note that these confirmed samples were collected from individuals in late October. There seems to be quite a delay in reporting positive/negative test results. It would be beneficial if test results on any suspected cases between November and today were more quickly announced.
 
Re: Pakistan: Bird Flu claims 2 lives; more suspects

Re: Pakistan: Bird Flu claims 2 lives; more suspects

Yes, it appears that teh more deatiled story presented several days ago, which mentioned the second familial cluster, the samples collected in October, and the November dates for the deaths of the two brothers had the most accurate early information.
 
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