Pakistan: Human H5N1 Cluster December 2007

[camster]

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

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

Testing after Tamiflu treatment produces false negatives.

how so? if the virus titers are reduced or non-existent and you are asymptomatic, you are clinically negative.

 

[HenryN]

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

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

how so? if the virus titers are reduced or non-existent and you are asymptomatic, you are clinically negative.

But still infected.

 

[HenryN]

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

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

how so? if the virus titers are reduced or non-existent and you are asymptomatic, you are clinically negative.

Although NY says there were no symptoms for the brother residing in the US, WHO said he had mild symptoms prior to visiting the doctor.

 

[camster]

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

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

But still infected.

if the virus is reduced below the limit of PCR detection, the chance of spreading the infection has to be severely reduced as well. at that point I think you are truly clinically negative.

 

[sharon sanders]

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

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

Welcome Camster.

 

[HenryN]

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

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

how so? if the virus titers are reduced or non-existent and you are asymptomatic, you are clinically negative.

Here is a little more detail on why this is not a closed issue. The brother was in Pakistan for some period (and the period is likely to be long based on the dates of death for his two brothers - Nov 19 and Nov 29). Thus, the chance that he was given Tamiflu in Pakistan is high. WHO said he had symptoms upon return to the US, and saw a private MD here. He subsequently tested negative, but that doesn't mean he wasn't infected in Pakistan, or infectious for a period when on Tamiflu. Negatives after treatment do not exclude infection in Pakistan or an infectious period prior or during the flight back. The NY report would seem to reduce the likelihood that the son was infected since he had symptoms prior to his father's return, but WHO has already acknowledged that some of the patients who were H5N1 positive in Pakistan had mild or no symptoms, so the number of open issues remains high (as do the number of published conflicting statements, including the health of the traveler while traveling).

 

[HenryN]

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

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

if the virus is reduced below the limit of PCR detection, the chance of spreading the infection has to be severely reduced as well. at that point I think you are truly clinically negative.

There are clearly two issues here. One is related to transmission, which could be via many mechanisms, including H5N1 on items originating in Pakistan, like the handles on luggage, etc,

The second is how long the transmissiojn chain is (i.e. like the vet infecting brother #1, who infected brother #2, who infected the health care worker, who infected the visiting brother). Of course transmission chains are more easily addressed with disease onset dates, and clarification of when patients were tested relative to symptoms and the start of Tamiflu treatment.

In the case of the brother, the question is when the samples were collected, and what tests were run. At this point, a test for H5 antibodies would be the most accurate test to determine if the brother was infected, and if positive, then the questions of how infectious he was at what time would be issues.

 

[Giuseppe]

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

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

It is important to know from where samples for testing were collected: from nasal or pharynx swabs, or via bronchoscopy or via blood sample. If were nasal samples and viral strain is a bit more adapt to replicate in low temperature environment, and in a immunological naive patient with an assumed more long viral shedding, then the test results may be more credible, or not?

 

[camster]

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

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

agreed that there is much information missing here, including further characterization of the virus and a description of the actual tests performed.

 

[Gert van der Hoek]

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

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

hat-tip Rickk

Three more bird flu victims detected in NWFP

NIH confirms two patients suffering from H5N1; Federal Health Ministry taking steps to control virus

Monday, December 17, 2007,

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 ñ a 10-year-old girl and a man ñ 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 ñ Muhammad Idrees and Muhammad Ilyas ñ 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." - excerpt

http://www.thenews.com.pk/top_story_detail.asp?Id=11764

Isn't this more or less the same report as posted yesterday by Treyfish:
# 190 ?

http://www.flutrackers.com/forum/showpost.php?p=116277&postcount=190

No new patients here?

 

[HenryN]

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

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

Fresh outbreak of bird flu claims two lives in Pakistan, says UN agency

<LEFT><TABLE cellSpacing=0 cellPadding=2 width=120 align=left border=0><TBODY><TR><TD align=VALIGN=TOP>

</TD></TR><TR><TD vAlign=top align=left>[SIZE=-2][/SIZE]</TD></TR></TBODY></TABLE>[SIZE=-1]17 December 2007 [/SIZE]? At least two Pakistanis have died in a fresh outbreak of avian influenza close to the country?s ?poultry belt,? the United Nations World Health Organization (WHO) has reported.
Pakistani health officials informed WHO of eight suspected human cases of infection with the H5N1 virus ? the virus responsible for outbreaks of bird flu around the world in recent years ? in the area around the city of Peshawar.
In an update issued at the weekend, WHO said two people have died in the outbreak and one person has now recovered.
The outbreak in humans was detected after a series of culling operations in the area in response to an outbreak of the virus in local poultry. Samples taken by health officials have tested positive in the national laboratory and are now being referred to a WHO laboratory for further analysis.
The agency is helping Pakistani health officials conduct epidemiological investigations and assess the current surveillance, prevention and control measures in place to see whether they need tightening or adjusting.
Pakistan has been hit by multiple outbreaks of bird flu in its domestic poultry population since last year, while this year there has also been outbreaks in wild birds.
WHO officials are also assisting local health authorities in Myanmar and Indonesia in response to outbreaks in those countries.
In Myanmar, a seven-year-old girl from Shan State (East) has recovered after developing symptoms of fevers and headaches last month. Samples from the case have tested positive for the H5N1 virus. Indonesian officials have confirmed that a 47-year-old man from the country?s Banten Province has bird flu and has been hospitalized since 9 December. So far, 115 human cases have been confirmed in Indonesia, and 92 have been fatal.

http://www.un.org/apps/news/story.asp?NewsID=25085&Cr=bird&Cr1=flu

 

[HenryN]

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

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

agreed that there is much information missing here, including further characterization of the virus and a description of the actual tests performed.

There is a Bloomberg story that should be out shortly and it will have more info on Tamiflu treatment and testing.

 

[camster]

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

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

yes, source of sample is very important to know. seeing infection in the upper respiratory tract would be cause for concern.

I think it's hard to predict some of your assumptions below w/o working with the virus somewhat. given those, it would be more credible, but I would think you'd still want a lower respiratory sample to be sure.

It is important to know from where samples for testing were collected: from nasal or pharynx swabs, or via bronchoscopy or via blood sample. If were nasal samples and viral strain is a bit more adapt to replicate in low temperature environment, and in a immunological naive patient with an assumed more long viral shedding, then the test results may be more credible, or not?

 

[Commonground]

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

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

Dutchy, it seems to be more or less the same. Treyfish's articles talks about the husband who was sleeping outside the isolation room where the brothers were. No new patients.

 

[HenryN]

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

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

AVIAN INFLUENZA, HUMAN (168): PAKISTAN
**************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Mon 17 Dec 2007
Source: The News International (Pakistan) [edited]
<http://thenews.jang.com.pk/top_story_detail.asp?Id=11770>


The Caretaker North Western Frontier Province (NWFP) Health Minister
Syed Kamal Shah expressed his dismay over the "continuous reluctance"
of the National Institute of Health (NIH) in providing the provincial
government with reports regarding the bird flu victims. Setting a
24-hour deadline to the NIH for releasing the report, he said that
the institute's denial or delay would be taken as they were hiding
the report for vested interests. Besides, Syed Kamal said that the
NWFP government was seriously considering closing down the poultry
business in the Frontier province. The Minister said 70 percent of
Pakistan's poultry industry was based in the 2 districts of the NWFP,
including Abbottabad and Mansehra, which he felt had been posing
serious threat to the lives of the local population.

It may be recalled that after the deaths of 2 brothers at the Khyber
Teaching Hospital (KTH) in Peshawar on 19 and 29 Oct [2007]
respectively, 3 more patients suffering from bird flu virus were
admitted to hospitals in Abbottabad and Peshawar.

In Ayub Medical Complex (AMC), Abbottabad, where 2 patients, [a 38
year old man] and a 10 year old girl, were admitted, doctors said
their condition was stable and they were sent home. Medical
Superintendent AMC Dr Iftikhar, when reached on telephone, told 'The
News' one of them was working at a poultry farm in Abbottabad while
the girl was living in the vicinity of the farm. "Their blood samples
had been sent to the NIH but the report is awaited," he said. Another
patient, who belongs to the nearby Palosai town, was admitted to the
KTH.

Dr Mukhtiar Zaman Afridi, who is a noted chest physician and in
charge of Pulmonology ward of the hospital, when contacted on
telephone said the patient was in a stable condition and his blood
samples had been sent to the NIH. Also, he said the report was
expected to be made available to them today [Mon 17 Dec 2007]). He
said the patient had been kept in an isolation room and was under his
personal observation. However, during a visit to the hospital (KTH)
on Sunday [16 Dec 2007], a number of doctors and health workers
complained to this correspondent that there was a mechanism to keep
them safe from the virus but the ventilator of the isolation room
where the patient had been kept was open and the virus could spread
around in the entire hospital through air. Also, this scribe found Dr
Mukhtiar Zaman Afridi was removing fears from the mind of his staff
created after the death of 2 brothers under their observation. The
majority of doctors, paramedics, and nurses were reluctant to go into
the isolation room to attend the patient.

However, Dr Mukhtiar's lecture persuaded his staff to continue
attending this altogether different patient. Despite being a public
holiday, Dr Mukhtiar was seen present in the hospital from early
morning to the evening where he regularly examined the patient.

It was dismal to note that the 2 isolation rooms where the 2 brothers
were kept and later died were found locked by the hospital
administration. Also, despite the passage of 2 weeks, the KTH
administration has failed to ensure sterilisation of equipment used
in attending the 2 brothers.

[Byline: Mushtaq Yusufzal]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[This report provides some dates and expresses local frustration at
the tardiness of the National Institute of Health of Pakistan in
communicating the results of diagnostic tests.

Two other suspected H5N1 cases have been admitted to hospital in
Abbottabad, one a poultry worker and the other a young girl living
near a farm. These cases further strengthen the link between human
infection and poultry and reduce the probability in this outbreak of
transmission of the virus by human-to-human transmission.

A map of the NWFP of Pakistan showing the poultry rearing areas of
Abbottabad and Mansehra can be accessed at
<http://encarta.msn.com/map_701515199/North-West_Frontier.html>. - Mod.CP]

[see also:
Avian influenza, human (167): Pakistan 20071216.4049
Avian influenza, human (166): Pakistan, WHO 20071215.4038
Avian influenza, human (165): Pakistan 20071214.4023
Avian influenza, human (163): Pakistan 1st report 20071213.4008]
...................................cp/mj/lm

 

[HenryN]

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

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

WHO: Bird flu is on the move again
Pakistan is reporting new infections and Myanmar has its first human case
The Associated Press
updated 1:51 p.m. ET, Mon., Dec. 17, 2007
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HANOI, Vietnam - The World Health Organization warned Monday that countries should be on alert for bird flu because it is again on the move, with Pakistan reporting new infections and Myanmar logging its first human case.
"The key to the public health response is surveillance," said Peter Cordingley, spokesman for the WHO Western Pacific region in Manila. "If we do actually get to the cases with antivirals early on, the health outcome is a lot better."
WHO experts arrived in Pakistan to try to sort out cases reported there, South Asia's first human infections. They were expected to visit a hospital and affected areas Tuesday, said WHO country representative Khalif Bile in Islamabad.
"They are here to get more information and to provide more support in the case of any potential risk," he said, adding that the Health Ministry, Agriculture Ministry and WHO are now working closely together following a "communication gap" when the government did not immediately report suspected cases to the WHO.
Four brothers and two cousins fell ill last month in Abbotabad, a small city north of Islamabad, while three others who slaughtered poultry in the same area and a nearby town tested positive for the H5N1 bird flu virus earlier this month.
Two of the brothers died, but specimens were collected from only one.
The cases were positive for H5N1 in initial government testing, but WHO will conduct further analysis to confirm the results.
Human-to-human transmission not ruled out
WHO spokesman Gregory Hartl in Geneva said Sunday human-to-human transmission had not been ruled out, but added that poultry outbreaks had earlier been reported in the area and it was unclear if all patients had links to sick birds or infected surroundings.
A doctor who cared for the brothers also experienced mild flu-like symptoms, but more testing needs to be carried out to determine if she was infected, Hartl said.
Two poultry farms near Abbotabad have been closed and health workers are taking temperatures of those living in the affected area twice a day, but no new suspected cases have been reported, said Minhajul Haq, a district health officer.
"We are on high alert, though we still await any confirmation of human-to-human transmission," he said.
At least 208 people have died from the virus, which began plaguing Asian poultry stocks in late 2003. It remains hard for people to catch, but scientists worry it could mutate into a form that spreads easily among people, potentially sparking a pandemic.
With fresh poultry outbreaks reported in a number of countries, including Germany over the weekend, WHO urged nations to be vigilant in identifying and reporting cases in both birds and humans.
93 have died so far in Indonesia
Myanmar's first human case was reported Friday in a 7-year-old girl who fell ill last month and survived, while Indonesia, the country hardest hit by the virus, has announced its 93rd death from the virus.
Two human cases were also recently confirmed in China, one of whom died.

The H5N1 virus often flares during the winter months. In some countries, like Indonesia, poultry outbreaks and human cases are reported year round, but many countries experience a flurry of activity when temperatures drop.
"It starts to pop at this time of the year, not just in this region where it's endemic, but it starts to appear in the West," Cordingley said. "Between now and April is a very dangerous time of the year."
Most human bird flu cases have been linked to sick birds, but experts suspect limited person-to-person transmission may have occurred in a few cases involving blood relatives.
URL: http://www.msnbc.msn.com/id/22299077/
<HR>

 

[sharon sanders]

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

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

Published online <abbr class="published" title="2007-12-17T19:15:17Z">17 December 2007</abbr> | Nature | doi:10.1038/news.2007.383
News
Large bird flu cluster emerges

Human cases in Pakistan could hint of person-to-person spread.
Declan Butler
<!-- -->

Punchstock
A team of experts from the World Heath Organization (WHO) is making its way north in Pakistan to investigate a cluster of at least eight cases of avian flu in people living near the Afghan border. They will be seeking to establish whether the disease is spreading, and whether the cases were caused by human-to-human transmission.
Cases of bird flu continue to occur worldwide, mostly in Indonesia, and this is the colder time of year when flu is expected to hit hardest in the northern hemisphere. But this latest outbreak is worrying in that it involves the biggest batch of closely related cases since a cluster of eight infected people was reported in Indonesia in May 2006.
"So far, we are not seeing anything different than in previous instances of H5N1 outbreaks," says Gregory Hartl, a spokesman for WHO, whose current information comes from Pakistani authorities.
The Pakistan cases started in mid-November, or possibly earlier, when five family members fell ill in Abbottabad, north of Islamabad. Two of the brothers have died, one of whom was buried before he could be tested for H5N1.
In December, a man and his niece in the same town were found to have H5N1. They are thought to have worked on the same farm as the first family affected. Another man was found to have H5N1 in a nearby town some distance from there. Another case is suspected but not yet confirmed, which would bring the cluster to nine.
Pakistan has had repeated outbreaks of avian flu in poultry over the past two years.
On the track

The WHO team will be tracking down, treating and testing people who came into contact with the infected cases. Monitoring for cases in the area will be key to establishing whether the virus has become more virulent or shows signs of spreading.
Meanwhile, Pakistani health authorities are poring over hospital records from the past few months to see, retrospectively, whether there has been any upsurge in the incidence of respiratory illnesses.


Human-to-human transmission cannot be ruled out, says Hartl, as it has occurred on a limited basis on several occasions in the past. Tests of 40 people who have had contact with the patients have so far all turned up negative. Genetic sequencing will help to pin down the mode of transmission and whether any important genetic changes have occurred in the virus.
Early warning

The Pakistan cluster highlights the obstacles faced by the WHO in containing the spread should a pandemic strain of H5N1 appear. The strategy calls for early diagnosis of cases, in the hope that blanket treatment with antivirals will stamp out an emerging pandemic before it spirals out of control. Computer models suggest that for this to have any chance of succeeding, WHO would have a window of three weeks for this diagnosis at most.

But although the first cases occurred in mid-November at the latest, Pakistan only officially informed WHO on 12 December, a day after the first media reports. WHO made the cases public on 15 December. (actually the first media reports were Dec. 10 - check the date of this thread- Fla1)


Last Friday, the WHO also confirmed the first case in Myanmar: a 7-year old girl from Kyaing Tone Township, Shan State, who was hospitalized in late November, and has since recovered. A WHO team has so far found no evidence of infections in any of the case's contacts or in the area.





http://www.nature.com/news/2007/071217/full/news.2007.383.html






<!-- end .entry-content -->

 

[sharon sanders]

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

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

Today I received this statement in my email from the CDC and I have permission to quote:

"From CDC,​

There are no reports of animal or human avian influenza A (H5N1) infections in the United States.​

• On December 7, 2007, the Centers for Disease Control and Prevention (CDC) was notified by the New York State Department of Health about a man in Nassau County, New York who had recently returned from Pakistan and who had contact with a person suspected of having been infected with avian influenza.

• The contact has since tested negative for influenza, H5 at the New York State Department of Health. This negative test result was confirmed at CDC by real-time reverse-transcriptase polymerase chain reaction (rtRT-PCR test).

• Upon returning from Pakistan to the United States, the contact was hospitalized for observation on December 6 and discharged on December 7. Voluntary home quarantine was in place until all specimens collected tested negative for avian influenza, H5 by real-time PCR on December 9."

​

 

[AlaskaDenise]

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

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

Commentary at

http://www.recombinomics.com/News/12170704/H5N1_Pakistan_US_False.html

Commentary

False H5N1 Negatives in Pakistan and the United States?

Recombinomics Commentary
December 17, 2007

The Health Ministry said it was treating people who had been in contact with those infected, setting up isolation wards and procuring drugs for treatment and protective clothing for health workers.

The above update raises additional questions regarding the spread of H5N1 in Pakistan and the United States. Testing of samples collected after the start of Tamiflu treatment can generate false negatives, since Tamiflu reduces viral load, which is the target of PCR testing. Earlier reports indicated several H5N1 patients had mild symptoms or were asymptomatic, but registered positive on a "less reliable" test, which was likely to be an H5 antibody test. This testing may be more reliable than PCR testing for patients who have already started Tamiflu treatment. Ideally, samples would be collected before or at the start of Tamiflu treatment.

The above information raises questions about the brother (38M) who returned to the US after attending funeral(s) of his two brothers in Pakistan (see Nassua County report). Since the dates of death were ten days apart (November 19 and 29), there would be significant exposure opportunities if the visiting brother was in Pakistan for both funerals.

The Nassua report indicates the patient was prescribed Tamiflu also, but it is unclear if specimens were collected before or after the start of treatment (which may have begun in Pakistan).

More information on the testing, including follow-up tests on convalescent, serum would be useful.


.

 

[HenryN]

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

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

Commentary at

http://www.recombinomics.com/News/12170705/H5N1_Pakistan_Cloudy.html