Concerns arise over symptomless Egypt bird flu cases

[Giuseppe]

Re: Concerns arise over symptomless Egypt bird flu cases

I continue to highlight the persistent lack of details about clinical course of pediatric H5N1 infections.

There aren't anamnestic details, vaccination status (ie: pneumococcal vaccine, Hemophilus Influenzae b vax etc.), treatment course, environmental and domestic hygiene descriptions.

WHO/FAO/OIE may start a wide sero-surveys activities but I wonder they could have some preliminary virological data suggesting changes in Hemagglutinin receptor binding domains and or in internal sub-units (ie: polymerase complex, nucleoprotein, non-structural ...)

If not, I think it is strange this upsurge in both Egyptian and foreign interest in less then a dozen of cases occurring during the last three months.

I suspect that the impending turmoil in Egyptian political scenario is playing a role in this incident.

A decades-long Egyptian regime is rumbling under internal and international pressure. The things don't happen almost alone...

We have:

1) a dozen of confirmed pediatric cases;
2) a time frame of several months;
3) different locations;
4) uncertain clinical courses, except for media sources and Egyptian official reports;
5) lack of clinical course and anamnestic description by the WHO;
6) no virological update by the WHO;
7) no clear epidemiologic changes described by the WHO;
8) no data about treatment courses and effectiveness of interventions;
9) widespread poultry epizootics;
10) poultry vaccinations effectiveness data is lacking;
11) environmental contamination of patient's houses unknown;
12) follow-up reports about pediatric cases by WHO continue to be absent.
13) increasing political turmoil;
14) civil unrests;
15) re-aligning international alliances and perspectives;
16) discrepancy in media interviews and statement and official public press releases by WHO;
17) unclear role of foreign laboratory and research facilities in Egypt.

I am surprised by the lack of travel warning for tourists directed to Egyptian resorts if there is a strong suspect of increased human-to-human transmissibility of H5N1 virus and likely existence of milder or abortive illness.

Migrants from Alexandria toward Italian Mediterranean Sea continue to arrive en masse.

No atypical or undiagnosed illness among them and among destination islands.

This post expresses only the opinions of the author (Inororehopper) and doesn't imply any endorsement by this website directors/members/owners.

(PS: Is it also possible that H5N1 virus involved in recent pediatric cases could have changed its human epithelial cells affinity or is it replication defective? Could be the virus resulted attenuated by exposure to environmental factors / solar radiation / dew / temperature?)

[HenryN]

Re: Concerns arise over symptomless Egypt bird flu cases

Table 5, passive surveillance of HPAI in the household poultry sector (page 11), reports 17 positive samples from 46 tests from 8 governorates, about 1 positive result for every three samples tested. However, 16 of the the tested samples were from Beheira (Behaira) where the two cousins were infected. Ten of the 16 samples, more than 60%, were positive, the highest percentage for any of the governorates that were subjected to testing.

This still leaves open the possibility that the infection of the the two children was B2H rather than H2H.

Beheira is a large governorate and the map of the outbreaks there clearly show ZERO confirmed cases near the cousins for the ENTIRE season (all of the poultry outbreaks, including those in March/April are in the north).

The H2H is WELL into the obvious category. The 4 day gap in disease onset dates is NOT a coincidence.

[HenryN]

Re: Concerns arise over symptomless Egypt bird flu cases

I continue to highlight the persistent lack of details about clinical course of pediatric H5N1 infections.

There aren't anamnestic details, vaccination status (ie: pneumococcal vaccine, Hemophilus Influenzae b vax etc.), treatment course, environmental and domestic hygiene descriptions.

WHO/FAO/OIE may start a wide sero-surveys activities but I wonder they could have some preliminary virological data suggesting changes in Hemagglutinin receptor binding domains and or in internal sub-units (ie: polymerase complex, nucleoprotein, non-structural ...)

If not, I think it is strange this upsurge in both Egyptian and foreign interest in less then a dozen of cases occurring during the last three months.

I suspect that the impending turmoil in Egyptian political scenario is playing a role in this incident.

A decades-long Egyptian regime is rumbling under internal and international pressure. The things don't happen almost alone...

We have:

1) a dozen of confirmed pediatric cases;
2) a time frame of several months;
3) different locations;
4) uncertain clinical courses, except for media sources and Egyptian official reports;
5) lack of clinical course and anamnestic description by the WHO;
6) no virological update by the WHO;
7) no clear epidemiologic changes described by the WHO;
8) no data about treatment courses and effectiveness of interventions;
9) widespread poultry epizootics;
10) poultry vaccinations effectiveness data is lacking;
11) environmental contamination of patient's houses unknown;
12) follow-up reports about pediatric cases by WHO continue to be absent.
13) increasing political turmoil;
14) civil unrests;
15) re-aligning international alliances and perspectives;
16) discrepancy in media interviews and statement and official public press releases by WHO;
17) unclear role of foreign laboratory and research facilities in Egypt.

I am surprised by the lack of travel warning for tourists directed to Egyptian resorts if there is a strong suspect of increased human-to-human transmissibility of H5N1 virus and likely existence of milder or abortive illness.

Migrants from Alexandria toward Italian Mediterranean Sea continue to arrive en masse.

No atypical or undiagnosed illness among them and among destination islands.

This post expresses only the opinions of the author (Inororehopper) and doesn't imply any endorsement by this website directors/members/owners.

(PS: Is it also possible that H5N1 virus involved in recent pediatric cases could have changed its human epithelial cells affinity or is it replication defective? Could be the virus resulted attenuated by exposure to environmental factors / solar radiation / dew / temperature?)

The mild cases in Egypt this year are a REPEAT of the mild cases in the spring of 2007, except the population target has changed. In 2007 the cases involved children, age 3-10. In 2009 the target population is toddlers, confirming that the 2007 cases were just the tip of a VERY large iceberg, which created protective immunity to H5N1 in a large segment of the population.

The mild cases were bracketed by severe cases. The CFR in the the 10 cases preceding the mild cases in 2007 was 100%. The cases between the two mild outbreaks involved cases that were in CRITICAL condition, and most died.

The low CFR in the two clusters of mild cases (1/17 in the spring of 2007 and 0/12 in 2009) is in addition to the fact that the patients not only didn't die, but most were never very sick and never developed pneumonia.

The low number of cases create concern, because the manipulation of the WHO case definition is OBVIOUS and has been OBVIOUS since 2005, which it was used to hide the mild cases in northern Vietnam (and has been used ever since to hide mild cases, as is done in India, where suspect cases that don't develop pneumonia are simply not tested).

[HenryN]

Re: Concerns arise over symptomless Egypt bird flu cases

AVIAN INFLUENZA, HUMAN (73): EGYPT, VIRULENCE
***********************************************
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 13 Apr 2009
Source: Bloomberg News online [edited]
<http://www.bloomberg.com/apps/news?p...3DakmwbqDeHpvE>


Egypt asked the World Health Organization [WHO] to help investigate
an outbreak of bird flu after a dozen non-fatal cases of the disease
this year [2009] prompted speculation the virus may be becoming less
virulent. Two WHO doctors and a scientist will travel to Cairo later
this week at the request of Egypt's Ministry of Health, said Gregory
Hartl, a spokesman for the United Nations agency in Geneva, in an
interview today [13 Apr 2009]. The UN team will assist local
authorities to identify how the patients were infected with the H5N1
strain of avian influenza and whether there have been any significant
changes in disease patterns in the virus itself.

Scientists have been following H5N1 for more than a decade because of
concern it could spark a pandemic if it becomes as infectious for
humans as it is for poultry. A less lethal strain could be more
contagious because people would have longer to transmit it through
coughing and sneezing. None of the 12 Egyptian cases reported to the
WHO this year [2009] has been fatal.

These data do indeed suggest that there may have been a reduction in
the virulence of the outbreak strain, and there is a perceived risk
of progression of the virus to a less virulent but more transmissible
form, the International Society for Infectious Diseases said today
[13 Apr 2009] in an e-mail via its ProMED-mail program [see, "Avian
influenza, human (72): Egypt, virulence 20090412.1403"]. The survival
of H5N1 patients in Egypt also may reflect early treatment with
antiviral medicines, ProMED said.

At least 417 people in 15 countries have contracted the virus since
2003. Three of every 5 cases worldwide were fatal. Most cases were
caused by contact with infected poultry, such as children playing
with them or adults butchering them or plucking feathers, according
to WHO.

H5N1 is continuing to circulate in poultry in Egypt, though there is
no evidence so far of any significant changes in the virus, said
Joseph Domenech, chief veterinary officer with the Food and
Agriculture Organization [FAO]. The Rome-based UN agency has also
agreed to a request by Egypt's government to provide technical
assistance, Domenech said in an interview today [13 Apr 2009].

Egypt has the highest number of avian-flu cases outside Asia, with 63
cases reported to WHO since 2006, of which 23 were fatal. In
comparison, more than 80 percent of the 141 people reported to have
been infected in Indonesia died.

Roche Holding AG says its Tamiflu antiviral medicine can reduce the
severity and duration of flu symptoms if taken within 48 hours of the
onset of disease. Early treatment for H5N1 may improve survival, some
uncontrolled studies have shown.

[Byline: Jason Gale]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[The participation of the FAO in the WHO-led investigation of the
current H5N1 epidemic situation in Egypt is a logical development. As
of today (13 Apr 2009), the 11 cases of avian H5N1 influenza virus
confirmed in 2009 (all children) remain alive. This is in marked
contrast to the period from 2006 to 2008 when 23 of 51 H5N1-confirmed
patients did not survive infection. This suggests that there may have
been a change in the virulence of the H5N1 virus circulating in Egypt
at the present time. While diminished virulence is clearly
advantageous for the Egyptian population, it is feared that reduction
in virulence may favor increased transmissibility of the virus, which
might have adverse consequences for the global population.

However, other factors such as the role of the age of the victims,
the absence of evidence of person-to-person transmission, and the
effectiveness of treatment protocols have still to be evaluated. An
update on the current situation is awaited. - Mod.CP]

[see also:
Avian influenza, human (72): Egypt, virulence 20090412.1403
Avian influenza, human (71): Egypt, Viet Nam, WHO 20090408.1359
Avian influenza, human (70): Egypt (QL), 63rd case 20090406.1336
Avian influenza, human (69): Egypt (BH) 62nd case 20090404.1299
Avian influenza, human (66): Egypt (BH) 20090402.1271
Avian influenza, human (59): Viet Nam (ST) NOT 20090325.1162
Avian influenza, human (56): Viet Nam (DT) NOT, (ST) susp. 20090321.1128
Avian influenza, human (55): Egypt (AT), Viet Nam (DT) 20090320.1118
2006
----
Avian influenza (208): NS1 virulence determinant 20061106.3183]
.................................................. ........cp/msp/lm
</pre>

[HenryN]

Re: Concerns arise over symptomless Egypt bird flu cases

AVIAN INFLUENZA, HUMAN (73): EGYPT, VIRULENCE
***********************************************


[The participation of the FAO in the WHO-led investigation of the
current H5N1 epidemic situation in Egypt is a logical development. As
of today (13 Apr 2009), the 11 cases of avian H5N1 influenza virus
confirmed in 2009 (all children) remain alive. This is in marked
contrast to the period from 2006 to 2008 when 23 of 51 H5N1-confirmed
patients did not survive infection. This suggests that there may have
been a change in the virulence of the H5N1 virus circulating in Egypt
at the present time. While diminished virulence is clearly
advantageous for the Egyptian population, it is feared that reduction
in virulence may favor increased transmissibility of the virus, which
might have adverse consequences for the global population.

However, other factors such as the role of the age of the victims,
the absence of evidence of person-to-person transmission, and the
effectiveness of treatment protocols have still to be evaluated. An
update on the current situation is awaited. - Mod.CP]

The point is that the mild cases in 2009 are a REPEAT of the mild cases in 2007 except the target population has changed from children, age 3-10, to toddlers, age 1 1/2 to 2 1/2. The mild cases of 2007 are combined with the 100&#37; CFR in the 10 patients prior to the mild cases, as well as the high CFR in the patients between to the two mild clusters to produce the rather normal (but low) CFR for the entire population prior to 2009.

This analysis hides the VERY glaring cluster in the spring of 2007, when only 1 of the 17 confirmed cases died, and extends the media myth that the mild cases in 2009 in Egypt are NEW, instead of a REPEAT (which signals H5N1 cases that are orders of magnitude higher than the confirmed cases).

[Giuseppe]

Re: Concerns arise over symptomless Egypt bird flu cases

The mild cases in Egypt this year are a REPEAT of the mild cases in the spring of 2007, except the population target has changed. In 2007 the cases involved children, age 3-10. In 2009 the target population is toddlers, confirming that the 2007 cases were just the tip of a VERY large iceberg, which created protective immunity to H5N1 in a large segment of the population.

The mild cases were bracketed by severe cases. The CFR in the the 10 cases preceding the mild cases in 2007 was 100%. The cases between the two mild outbreaks involved cases that were in CRITICAL condition, and most died.

The low CFR in the two clusters of mild cases (1/17 in the spring of 2007 and 0/12 in 2009) is in addition to the fact that the patients not only didn't die, but most were never very sick and never developed pneumonia.

The low number of cases create concern, because the manipulation of the WHO case definition is OBVIOUS and has been OBVIOUS since 2005, which it was used to hide the mild cases in northern Vietnam (and has been used ever since to hide mild cases, as is done in India, where suspect cases that don't develop pneumonia are simply not tested).

I know well as nonfatal cases aren't a news, as the history of H5N1 panzootics is now longer and longer.

Despite that, none of my questions have found a reply.

It this story is so obvious, why does nobody seem able to explain to large public almost a couple of the above questions?

It could be the case that the questions per se would be stupid or irrelevant but the aim of a public forum with a number of non-professional readers and contributors should be to make clear facts amidst the instense fog of media.

[sharon sanders]

Re: Concerns arise over symptomless Egypt bird flu cases

"..but the aim of a public forum with a number of non-professional readers and contributors should be to make clear facts amidst the instense fog of media."

I agree.

Your points in post # 91 are very pertinent.

[vinny]

Re: Concerns arise over symptomless Egypt bird flu cases

Does anyone think a pandemic could be close then,with whats happening in egypt.the reason i ask is because we no longer have a preps and i would need to restock,thanks.

[Giuseppe]

Re: Concerns arise over symptomless Egypt bird flu cases

Does anyone think a pandemic could be close then,with whats happening in egypt.the reason i ask is because we no longer have a preps and i would need to restock,thanks.

Disaster preparedness is a valuable activity, and should be done even for other natural or man-made disaster such as eartquakes, floods, hurricanes, civil unrests etc.

So, if you want to restock your personal stockpile, you can done this without problems.

It is enough you save money to daily life, ...

[Commonground]

Re: Concerns arise over symptomless Egypt bird flu cases

"..but the aim of a public forum with a number of non-professional readers and contributors should be to make clear facts amidst the instense fog of media."

the aim should be to make clear facts. Clear facts from whom?

[sharon sanders]

Re: Concerns arise over symptomless Egypt bird flu cases

I think IOH means that our contribution as a forum is to make clearer the various data and other information that we see from other media and sources.

All of flublogia makes clearer the fog of the data that is in the media. We have seen many rumours, false information, and actual denials that an influenza pandemic may re-occur.

We analyze, debate, and present our responses and data, and in the end, make a valuable contribution to the body of information that exists in the general media regarding bird flu and other issues.

[HenryN]

Re: Concerns arise over symptomless Egypt bird flu cases

WHO/FAO/OIE may start a wide sero-surveys activities but I wonder they could have some preliminary virological data suggesting changes in Hemagglutinin receptor binding domains and or in internal sub-units (ie: polymerase complex, nucleoprotein, non-structural ...)

The 3 BP deletion removes S129, which is involved in receptor binding. There is a MAJOR problem in Egypt and those doing the planning have seen the sequences.

[HenryN]

Re: Concerns arise over symptomless Egypt bird flu cases

WHO/FAO/OIE may start a wide sero-surveys activities but I wonder they could have some preliminary virological data suggesting changes in Hemagglutinin receptor binding domains and or in internal sub-units (ie: polymerase complex, nucleoprotein, non-structural ...)

Here's the problem

http://www.recombinomics.com/News/04150901/H5N1_Egypt_S129del.html

[AlaskaDenise]

Re: Concerns arise over symptomless Egypt bird flu cases

Here's the problem

http://www.recombinomics.com/News/04...t_S129del.html

Commentary

H5N1 Receptor Binding Domain Changes In Egypt

Recombinomics Commentary 04:27
April 15, 2009

Similarly the results of H5N1 strains from Egypt (Figure 2) may be indicative of a possible viral evolution towards receptor usage similar to that of H1N1 viruses, which efficiently replicate in the upper respiratory tract. The protein domain, which seems to be involved in this subtle change, corresponds to amino acid domain 99-132.

The above comments, from ?Characterization of conserved properties of hemagglutinin of H5N1 and human influenza viruses: possible consequences for therapy and infection control? describe a subset of H5N1 sequences from Egypt that have chacteristics that match H1N1 seasonal flu. These matches include sequences from the Ghabiya cluster, as well as two Qena siblings with mild H5N1 in the spring of 2007. The sequences from the siblings had a 3 BP deletion that produce S129del, which is within the region listed above, Although the disease onset date of the index case was withheld from the WHO update, the hospital admission dates were four days apart, signaling the infection of the brother (4M) by his sister (6F). The sequences from the Qena siblings were identical, further supporting H2H transmission. Moreover, additional family members had symptoms, but tested negative.

This year there has been another cycle of mild cases in Egypt, but instead of affecting children between the ages of 3 and 10, like the siblings above, 10/12 cases are toddlers. However, like the cases in the spring of the 2007, the case fatality rate is low (in 2007 only 1/17 died, and this year 0/12 have died) and most patients did not develop pneumonia. These mild cases, coupled with the younger age group, raise concerns that H5N1 spread in the past two year was far more extensive than indicated by the confirmed cases, and were missed by current testing, which requires a poultry contact for H5N1 PCR testing.

Although NAMRU-3 has not released any human or poultry sequences this year, the first two human isolates were represented in a recent HA tree of vaccine targets. Although public sequences are not on the branch with the 2009 isolates, the location of the branch suggests these isolates also have the 3 BP deletion and are closely related to the sequences in the siblings from 2007.

The four day gap in admission dates for the Qena siblings, matches the four day gap in the disease onset dates for two cousins (both 2M) from Beheira. The cousins are next door neighbors, and the four day gap also indicated human to human transmission, further supporting the spread of mild H5N1.

The 3 BP deletion produces S129del and position 129 is in the receptor binding domain. This deletion maps to the region in H5N1 with similarities with H1N1, suggesting more efficient transmission, consistent with the clusters in Qena and Beheira.

Release of the sequences from the H5N1 cases this year would be useful. If these sequences have the same deletion as seen in the Qena cluster, an extensive screening of toddlers without a poultry connect is critical.

The failure to recognize the significance of the mild cases in 2007 is cause for concern. The failure to aggressively act at this time is beyond scandalous, and is hazardous to the world?s health.

.

[AlaskaDenise]

Re: Concerns arise over symptomless Egypt bird flu cases

...maps to the region in H5N1 with similarities with H1N1 suggesting more efficient transmission...

Does this mean this strain has a binding more similar to H1N1, or that the entire region is more similar? If it's the region, does that imply that this region may contain some of the "unknown" factors that potentially contribute to a pandemic influenza?

.