Re: Pakistan: December 18+, WHO Begins Investigations
Quote:
Originally Posted by Snicklefritz
Dr. Niman,
I have been following your commentaries on your site for two years now, and I know that you post many commentaries that relate specifically to the role of recombination in H5N1 evolution. However, the events in Pakistan appear, in your most recent commentaries, without statements about whether they prove your ideas about recombination. For that, very many people are grateful for your ability to focus on the danger to everyone regardless of how the danger evolves.
You recently posted: "Local confirmation of the initial lab positives was projected to be completed yesterday, and disease onset dates for the cluster members should have been known for some time. This information is usually released in WHO situation updates, which give the age and gender of confirmed cases, as well as disease onset dates, hospitalization dates, and dates of death as well as relationships between cluster members.
Virtually all of the data has not been released even though the outbreak began almost 2 months ago, and WHO has been aware of this cluster for at least a week."
Are you suggesting that the missing information described above is known and is intentionally being withheld by either the Pakistani Government or WHO? And if so, why do think they might be witholding this information?
Regards, Snicklefritz
In addition to Dr. Niman's commentaries, this thread also answers your question:
Re: Pakistan: December 18+, WHO Begins Investigations
WHO warns Pakistanis to be mindful of bird flu amid country’s first human cases
(AP)
20 December 2007
ISLAMABAD, Pakistan -The World Health Organization warned Pakistanis on Thursday to take precautions while handling poultry as experts investigate the country’s first human bird flu cases.
No new cases have been discovered since a WHO team arrived earlier this week, but health workers have been on high alert to monitor patients with flu-like symptoms who could be infected with the H5N1 bird flu virus, said Khalif Bile, the WHO country representative.
The Health Ministry has detected up to nine suspect cases who fell ill earlier this month and in November, including several siblings. The WHO experts were working to piece together how they became infected and whether human-to-human transmission could have occurred. Poultry outbreaks had been reported in the area before the human cases.
As many travelers head home for the Islamic holiday of Eid Al Adha, Bile said care should be taken when slaughtering and preparing poultry. He said the Health Ministry was reiterating the message with a public awareness campaign.
The public is being informed through the media what precautions to take without any alarm,’ he said. I think the situation so far seems to be under control, but we are monitoring it.’
A second team from the US Naval Medical Research Unit No. 3 in Cairo arrived in Pakistan on Thursday. They were expected to retest samples already gathered from a number of patients who were positive for the H5N1 virus in initial government analysis.
The WHO team has been working with hospital staff to strengthen infection control measures, while doing detective work to try to determine the relationship of the cases, when they were sickened and whether they were in contact with poultry.
The hospitals are much better organized,’ Bile said. They have been seen by WHO, and there are no cases as of today or yesterday. They are there to address all of the potential risks.’
At least 209 people have died worldwide from the virus, which began plaguing Asian poultry stocks in late 2003, according to the WHO. 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.
(Adds comments by WHO in Geneva)
A team from the U.S. Naval Medical Research Unit NAMRU-3 laboratory in Cairo has also arrived in Pakistan to test samples from the suspected human bird flu cases, the WHO said on Thursday. "They are setting up their laboratory and starting to work with the samples," WHO spokesman Gregory Hartl said in Geneva. The team, composed of two experts, will test samples taken from the suspected cases. The WHO requires additional testing by one of its network of collaborating laboratories, which includes NAMRU.
__________________
"In the beginning of change, the patriot is a scarce man (or woman), and brave, and hated and scorned. When his cause succeeds, the timid join him, for it then costs nothing to be a patriot."- Mark Twain Reason obeys itself; and ignorance submits to whatever is dictated to it. -Thomas Paine
Sustained Human to Human H5N1 Transmission in Pakistan?
Recombinomics Commentary
December 19, 2007
"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 told Reuters 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.
In Thailand, a mother was killed by the virus in 2004 after cradling her dying infected daughter all night. The largest known cluster of human bird flu cases worldwide occurred in May 2006 in Indonesia's North Sumatra province, where as many as seven people in an extended family died.
The above comments on the human to human (H2H) transmission in Pakistan, and two examples of such infections in the past are accurate, but the extensive H2H transmission in Pakistan is likely to cause confusion, because media reports and the public believe that H2H of H5N1 is rare, when it is very common. The more extended transmission chains, as noted above, are rarer, and the transmission in Pakistan may be the most sustained H2H reported to date, but H2H among family members is quite common, and most first reports of H5N1 in patients are H2H clusters.
The H5N1 H2H usually involves only two people, which are the index case and a family member caring for the index case. These small clusters have the diagnostic time gap between onset dates, but the linkage of the index case to a poultry source extends to a family member, so the proof of H2H is not absolute.
When there are two time gaps, suggesting H2H2H, then the likelihood of H2H increases markedly, especially when there is epidemiological data linking the cases.
However, the number of cited H2H examples is also reduced because samples are frequently not collected from the index case, and testing of contacts may use samples collected after the start of prophylactic oseltamivir (Tamiflu) treatment.
In the first example above. The lack of a poultry connection added to the likelihood that H2H was involved, and the number in the cluster was three and there were two time gaps. Therefore, it has been cited as the first example of H2H. The index case was a child staying with her aunt in rural Thailand. Her mother was an office worker in Bangkok. The index case was likely infected by a pet chicken, which died and was buried by the child. However, she was mis-diagnosed as having dengue fever. Consequently, there was no protective equipment given to her visiting mother, who was probably infected while holding her daughter in the hospital. The daughter died and was never tested for H5N1, but the mother developed symptoms after returning to Bangkok, and the aunt of the index case also developed symptoms several days after the mother left. Initially the mother was not tested either, but after she died, a nurse notified investigators of the bird flu symptoms, and samples were collected just prior to cremation. The mother was H5N1 positive and the aunt was also H5N1 positive, although initial tests on the aunt were inconclusive. Thus, if there wasn’t a cluster, it is likely hat none of the cases would have been official confirmed cases. However, because of the lab confirmation in the mother and aunt, the cluster is a strong example of H2H or H2H2H.
The cluster in Indonesia is also considered to be a cluster because there were two time gaps, and there was epidemiological evidence for H2H2H. However, the index case died prior to collection of a sample. Seven family members tested positive for H5N1 and the onset of symptoms was several days after the index case, most of whom slept in the same room as the index case while she was very sick and coughing extensively. The son of one of the infected brothers also developed symptoms several days after his father, so the Indonesia clusters was H2H2H, although the index case was not lab confirmed.
Most clusters however only involve two family members. The first cases in Cambodia were a cluster. The index case collected dead chickens. He developed bird flu symptoms and died prior to sample collection. When his sister developed symptoms, she went to Vietnam for treatment and was H5N1 confirmed after she died, so although the brother likely infected his sister, the cluster was not considered H2H because no sample was collected from the brother. The first cases in Hunan China were also a cluster with a time gap, but were not considered a cluster until a rising antibody titer was detected in the index case after he died. The first cases in Indonesia were also a cluster, but there were no early samples from the index case, no sample was collected from her sister, and H5N1 was confirmed in the father after his two daughters had died. This cluster had two time gaps, but one sister was not an official case because she was not tested.
There are dozens of similar examples. Some of the earlier clusters from Vietnam and Thailand were published, but there have been many examples since the earlier clusters were reported, and these clusters include the first case from Turkey, Iraq, Azerbaijan, and Nigeria. All of these cases involve the Qinghai strain of H5N1, which is almost certainly the case fro the cluster from Pakistan.
However, this cluster is likely to the most sustained to date. The index case was a veterinarian who developed symptoms on October 25. Two brothers developed symptoms after visiting the index case in the hospital, and the dates of death on November 19 and 29 suggest this transmission chain was H2H2H. However, at least two more brothers were infected, and one or two health care workers had symptoms or were H5N1 confirmed, so they represent H2H2H2H, if confirmed, and since one is still hospitalized, the transmission has been sustained for two months. Moreover, samples of contacts are being collected after the start of Tamiflu treatment, so additional transmissions may not be lab confirmed.
The detail of this cluster will be clearer when disease onset dates are released, but the current cluster appears to be the most sustained H5N1 cluster reported to date, and also representing the largest number of links on the chain.
__________________
"In the beginning of change, the patriot is a scarce man (or woman), and brave, and hated and scorned. When his cause succeeds, the timid join him, for it then costs nothing to be a patriot."- Mark Twain Reason obeys itself; and ignorance submits to whatever is dictated to it. -Thomas Paine
Re: Pakistan: December 18+, WHO Begins Investigations
Pakistan urges culling after bird flu outbreak
(Reuters)
20 December 2007
ISLAMABAD - Pakistan is urging provincial authorities to obey health guidelines to stop any bird flu outbreaks after fears lapses in poultry culling methods led to eight people being infected with the H5N1 virus.
The Health Ministry is sending out messages via radio and pamphlets to villages and farms in North West Frontier Province, where the eight people, including a veterinarian involved in culling, were infected in South Asia’s first human cases.
The vet’s brother died of bird flu. A third brother also died but it is unclear if he was also infected with the virus.
“These winter months are critical,” Federal Health Secretary Khushnood Akhtar Lashari told Reuters on Thursday.
“We are asking provincial authorities to adhere to safely guidelines, but it is quite difficult because many of these places are in remote areas and many people have the attitude that ’it can’t happen to me’.”
Authorities now believe there is no threat of a pandemic from the bird flu cases in Pakistan as World Health Organisation (WHO) experts carried out tests in the region.
But the H5N1 thrives best in winter months in part because people spend more time indoors and in close proximity to each other and their livestock.
Lashari said the man believed to have been infected first, a veterinarian who helped operations to cull chickens and who has now recovered, might have not worn a mask because he suffered from asthma.
He might also have taken his culling equipment back home with him. While he recovered, his two brothers died.
Six people have since recovered, while the remaining case is still being treated, the Health Ministry says.
The case highlights the difficulty of health control in Pakistan, where the health system is weak, particularly in the countryside. Many villagers are also illiterate, making communications harder.
Team arrives
In the Pakistan cases, the WHO said they were likely to be a combination of infections from poultry and limited human-to-human transmission of the H5N1 avian flu virus due to close contact.
The WHO says a similar case occurred in Indonesia in 2006 among family members believed to have contracted the virus while caring for sick loved ones.
The H5N1 virus is hard for humans to catch and is mainly a bird disease. But experts fear the strain could spark a global pandemic and kill millions if it mutates into a form that spreads easily between people.
A WHO team, led by Hassan El-Bushra of its regional Cairo office, have been in Pakistan this week helping investigate the outbreak.
A team from the U.S. Naval Medical Research Unit NAMRU-3 laboratory in Cairo has also arrived in Pakistan to test samples from the suspected human bird flu cases, the WHO said on Thursday.
“They are setting up their laboratory and starting to work with the samples,” WHO spokesman Gregory Hartl said in Geneva.
The team, composed of two experts, will test samples taken from the suspected cases.
The WHO requires additional testing by one of its network of collaborating laboratories, which includes NAMRU.
Since H5N1 resurfaced in Asia in late 2003, the virus has killed 209 people in 11 countries, according to the WHO. The latest Pakistan cases have yet to be included in the formal WHO tally.
Re: Pakistan: December 18+, WHO Begins Investigations
Workshop on Bird Flu
Staff Reporter
LAHORE: Eid travel will not increase the risk of the bird flu transfer to the peoples visiting the NWFP. Bird flu is not a contagious disease and does not spread with casual contacts or shaking hands, hugging or embracing. The only way it can spread to the human being is close and continuous contacts with the birds affected by this disease. These views were expressed by Chairman PMS Dr. Masood Akhtar sheikh while addressing the workshop in connection with the "Bird flu" under the auspices of Pakistan Medical Society.
He opined that if the chicken are kept for 3 days in the shops and are still healthy, it is a reasonably safe to say they are not affected by the serious form of the bird flu. The peoples related with the poultry should take precaution and use soaps and hot water to disinfect there hands or face on return from the poultry farms.
Re: Pakistan: December 18+, WHO Begins Investigations
Pakistan warned of bird flu by WHO
Islamabad, Dec. 20: The World Health Organisation warned Pakistanis on Thursday to take precautions while handling poultry as experts investigate the country’s first human bird flu cases. No new cases have been discovered since a WHO team arrived earlier this week, but health workers have been on high alert to monitor patients with flu-like symptoms who could be infected with the H5N1 bird flu virus, said Khalif Bile, the WHO country representative.
The health ministry has detected up to nine suspect cases who fell ill earlier this month and in November, including several siblings. The WHO experts were working to piece together how they became infected and whether human-to-human transmission could have occurred.
Poultry outbreaks had been reported in the area before the human cases. As many travellers head home for the Islamic holiday of Id ul-Zuha, Mr Bile said care should be taken when slaughtering and preparing poultry. He said the health ministry was reiterating the message with a public awareness campaign. "The public is being informed through the media what precautions to take without any alarm," he said. (AP)http://www.asianage.com/presentation...lu-by-who.aspx
Re: Pakistan: December 18+, WHO Begins Investigations
Quote:
Originally Posted by Niko
Commentary
Sustained Human to Human H5N1 Transmission in Pakistan?
Recombinomics Commentary
December 19, 2007
"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 told Reuters 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.
In Thailand, a mother was killed by the virus in 2004 after cradling her dying infected daughter all night. The largest known cluster of human bird flu cases worldwide occurred in May 2006 in Indonesia's North Sumatra province, where as many as seven people in an extended family died.
The above comments on the human to human (H2H) transmission in Pakistan, and two examples of such infections in the past are accurate, but the extensive H2H transmission in Pakistan is likely to cause confusion, because media reports and the public believe that H2H of H5N1 is rare, when it is very common. The more extended transmission chains, as noted above, are rarer, and the transmission in Pakistan may be the most sustained H2H reported to date, but H2H among family members is quite common, and most first reports of H5N1 in patients are H2H clusters.
The H5N1 H2H usually involves only two people, which are the index case and a family member caring for the index case. These small clusters have the diagnostic time gap between onset dates, but the linkage of the index case to a poultry source extends to a family member, so the proof of H2H is not absolute.
When there are two time gaps, suggesting H2H2H, then the likelihood of H2H increases markedly, especially when there is epidemiological data linking the cases.
However, the number of cited H2H examples is also reduced because samples are frequently not collected from the index case, and testing of contacts may use samples collected after the start of prophylactic oseltamivir (Tamiflu) treatment.
In the first example above. The lack of a poultry connection added to the likelihood that H2H was involved, and the number in the cluster was three and there were two time gaps. Therefore, it has been cited as the first example of H2H. The index case was a child staying with her aunt in rural Thailand. Her mother was an office worker in Bangkok. The index case was likely infected by a pet chicken, which died and was buried by the child. However, she was mis-diagnosed as having dengue fever. Consequently, there was no protective equipment given to her visiting mother, who was probably infected while holding her daughter in the hospital. The daughter died and was never tested for H5N1, but the mother developed symptoms after returning to Bangkok, and the aunt of the index case also developed symptoms several days after the mother left. Initially the mother was not tested either, but after she died, a nurse notified investigators of the bird flu symptoms, and samples were collected just prior to cremation. The mother was H5N1 positive and the aunt was also H5N1 positive, although initial tests on the aunt were inconclusive. Thus, if there wasn’t a cluster, it is likely hat none of the cases would have been official confirmed cases. However, because of the lab confirmation in the mother and aunt, the cluster is a strong example of H2H or H2H2H.
The cluster in Indonesia is also considered to be a cluster because there were two time gaps, and there was epidemiological evidence for H2H2H. However, the index case died prior to collection of a sample. Seven family members tested positive for H5N1 and the onset of symptoms was several days after the index case, most of whom slept in the same room as the index case while she was very sick and coughing extensively. The son of one of the infected brothers also developed symptoms several days after his father, so the Indonesia clusters was H2H2H, although the index case was not lab confirmed.
Most clusters however only involve two family members. The first cases in Cambodia were a cluster. The index case collected dead chickens. He developed bird flu symptoms and died prior to sample collection. When his sister developed symptoms, she went to Vietnam for treatment and was H5N1 confirmed after she died, so although the brother likely infected his sister, the cluster was not considered H2H because no sample was collected from the brother. The first cases in Hunan China were also a cluster with a time gap, but were not considered a cluster until a rising antibody titer was detected in the index case after he died. The first cases in Indonesia were also a cluster, but there were no early samples from the index case, no sample was collected from her sister, and H5N1 was confirmed in the father after his two daughters had died. This cluster had two time gaps, but one sister was not an official case because she was not tested.
There are dozens of similar examples. Some of the earlier clusters from Vietnam and Thailand were published, but there have been many examples since the earlier clusters were reported, and these clusters include the first case from Turkey, Iraq, Azerbaijan, and Nigeria. All of these cases involve the Qinghai strain of H5N1, which is almost certainly the case fro the cluster from Pakistan.
However, this cluster is likely to the most sustained to date. The index case was a veterinarian who developed symptoms on October 25. Two brothers developed symptoms after visiting the index case in the hospital, and the dates of death on November 19 and 29 suggest this transmission chain was H2H2H. However, at least two more brothers were infected, and one or two health care workers had symptoms or were H5N1 confirmed, so they represent H2H2H2H, if confirmed, and since one is still hospitalized, the transmission has been sustained for two months. Moreover, samples of contacts are being collected after the start of Tamiflu treatment, so additional transmissions may not be lab confirmed.
The detail of this cluster will be clearer when disease onset dates are released, but the current cluster appears to be the most sustained H5N1 cluster reported to date, and also representing the largest number of links on the chain.
Re: Pakistan: December 18+, WHO Begins Investigations
Bird flu a clear, present danger, says WHO
ISLAMABAD: The World Health Organisation warned Pakistanis on Thursday to take precautions while handling poultry as experts investigate the country's first human bird flu cases.
No new cases have been discovered since a WHO team arrived earlier this week, but health workers have been on high alert to monitor patients with flu-like symptoms who could be infected with the H5N1 bird flu virus, said Khalif Bile, the WHO country representative.
The Health Ministry has detected up to nine suspect cases who fell ill earlier this month and in November, including several siblings. The WHO experts were working to piece together how they became infected and whether human-to-human transmission could have occurred. Poultry outbreaks had been reported in the area before the human cases.
As many travellers head home for the Islamic holiday of Eidul Azha, Bile said care should be taken when slaughtering and preparing poultry. He said the Health Ministry was reiterating the message with a public awareness campaign.
"The public is being informed through the media what precautions to take without any alarm," he said. "I think the situation so far seems to be under control, but we are monitoring it."
A second team from the US Naval Medical Research Unit No. 3 in Cairo arrived in Pakistan on Thursday. They were expected to retest samples already gathered from a number of patients who were positive for the H5N1 virus in initial government analysis.
The WHO team has been working with hospital staff to strengthen infection control measures, while doing detective work to try to determine the relationship of the cases, when they were sickened and whether they were in contact with poultry.
"The hospitals are much better organised," Bile said. "They have been seen by WHO, and there are no cases as of today or yesterday. They are there to address all of the potential risks." - AFPhttp://statesman.com.pk/topnews/topnews.htm
Re: Pakistan: December 18+, WHO Begins Investigations
Following up on Niman's comments about the Pakistan cluster, two things stand out regarding the index case of this cluster. First samples were collected from him and second he survived. As noted by Niman most index cases in clusters are never tested because the infection is not recognized as H5N1. Because the infection is not recognized as H5N1, very few of these index cases receive antiviral treatment in time and they almost never survive. Probably less than 10% percent of index cases in clusters have survived.
Re: Pakistan: December 18+, WHO Begins Investigations
Quote:
Originally Posted by AnneZ
Thank you Dr Niman for commentary on Sustained Human to Human H5N1 Transmission in Pakistan?
What proportion of cases world wide do you consider to be h2h, either confirmed or highly suspected?
There is fluctuation from location to location. In Vietnam it was about 1/3. In Indonesia initially it was closer to 1/2. Almost all cases in Turkey, Iraq, and Azerbaijan were in clusters and most looked like H2H. Lately the number of clusters in Indonesia has been lower and clusters are fairly rare in Egypt.
Re: Pakistan: December 18+, WHO Begins Investigations
Hospitals taking measures to tackle bird flu threat
By Muhammad Qasim
12/21/2007
Rawalpindi
The hospitals at the twin cities have taken several steps to deal with any untoward situation in case of an outbreak of avian influenza in humans in light of recommendations given by National Institute of Health.
NIH has asked almost all healthcare facilities at both the provincial and federal levels to be ready to receive bird flu patients after confirmation of Avian Influenza - bird flu H5N1 virus - in birds in various parts of country. However, many of the hospitals in town have received no guidelines from the NIH so far.
“We have circulated instructions, on treatment and management of the infection, to our staff in case they receive a patient showing symptoms of avian influenza strain,” said the RGH chief Dr Habib Ahmed Khan while talking to ‘The News’.
He said a protocol has been circulated among the staff, which provides guidelines for handling and treatment of a patient with strain of avian influenza and as well has identified ward to be isolated in case of bird flu outbreak.
To a query, Dr Habib said his hospital had taken all possible pre-cautionary measures to contain the virus if that is detected in some patient at the RGH. “We have also made arrangements for proper management and treatment of patients of the infection during Eid holidays from December 20 to December 23 and have collected as many as 50 doses of Temiflu for treatment of patients with strain of avian influenza,” he said. Temiflu can reduce severity and duration of illness caused by avian influenza.
Within last three weeks, number of avian influenza outbreaks has been reported in areas of NWFP and federal capital including Islamabad, Murree, Abbottabad, Mansehra and adjoining areas and the NIH had also confirmed high concentration of H5N1 influenza virus in these areas. According to NIH, the high concentration may pose a serious threat to human health.
District Headquarters Hospital (Civil Hospital), one of the three teaching hospitals in town, has taken no initiative for handling patients showing symptoms of avian influenza. “We have received no advice on the subject from the NIH,” said DHQ hospital chief Dr Khalid Iqbal Malik while talking to ‘The News’ Thursday. He also admitted that there is no drug available at the DHQ for treatment of a patient conceived avian influenza virus.
The Holy Family Hospital has also made no special arrangements on the subject of adequate stock of Tamiflu, ventilators, nursing and personal protective equipment (PPE).
Studies reveal that avian influenza spread from birds to humans and not person-to-person however, scientists fear that combination of avian flu strain with human variant of influenza may result in a novel virus strain that can pass easily from person to person and cause a global epidemic killing millions of people. The greatest disaster on the subject was the “Spanish flu” outbreak in 1918 - originated from avian viral strain - that claimed 20 million to 50 million lives around the world. The most effective way of fighting avian influenza presently available to man is destruction of infected birds or those at risk of infection.
Seabirds, shorebirds, and other wildfowl contain avian influenza viruses and through faecal droppings infect domesticated birds for which it is fatal. Nasal and faecal secretions of sick birds spread illness to other poultry in both the farm enclosures and live animal markets.
Re: Pakistan: December 18+, WHO Begins Investigations
Workshop
LAHORE, Dec 20: If a chicken is kept for three days in a shop and is still healthy, it is not affected by any form of bird flu, says Pakistan Medical Society president Dr Masood Akhtar Sheikh. — Staff Reporter http://www.dawn.com/2007/12/21/nat13.htm
Re: Pakistan: December 18+, WHO Begins Investigations
Hat-tip, unpathedhaunts!
Bird flu claims first two lives in Pakistan
Dec 21, 2007
By our correspondent
PESHAWAR: The administration of Khyber Teaching Hospital on Thursday confirmed that two brothers Mohammad Ilyas and Tariq, who were brought to the hospital from Mansehra on suspicion of carrying H5N1, died of bird flu Monday last.
"The two brothers have been confirmed as bird flu victims and are the first human sufferers of the disease in our country," Dr Siddiqur Rahman, Acting Chief Executive of KTH, told The News on Thursday.
Mohammad Ilyas and Tariq were working at a poultry farm in Mansehra and were brought to KTH in a serious condition. They were suffering from pneumonia and were kept in the isolation ward, said Dr Rahman.
One of them was in critical condition at the time of arrival, Dr Rahman said. He added that the Ministry of Health after their expiry took blood samples and sent them to Islamabad to verify if they were carrying Bird Flu virus (H5N1). "Then I don't know what happened to the test," he added.
Meanwhile, some reports on Thursday suggested that the laboratory test conducted in Islamabad confirmed Bird Flu influenza. A spokesman of Health Ministry in Islamabad said that they had died of bird flu, adding both the brothers were working in a poultry farm in Mansehra and had direct link with the chickens that resulted in the transfer of the virus (H5N1) into them.
Re: Pakistan: December 18+, WHO Begins Investigations
Quote:
Bird flu claims first two lives in Pakistan Dec 21, 2007
By our correspondent
PESHAWAR: The administration of Khyber Teaching Hospital on Thursday confirmed that two brothers Mohammad Ilyas and Tariq, who were brought to the hospital from Mansehra on suspicion of carrying H5N1, died of bird flu Monday last.
How many times are these two Durrani brothers going to die?
The two deaths occurred in November, not last week.
The story is also incorrect because Tariq is not one of the brothers who died. He is shown alive and breathing on December 16th in a wire service photo with his surviving brother Ishtiaq, the verterinarian.
Quote:
Pakistani brothers Mohammed Ishtiaq, right, and Mohammed Tariq, left, who were treated for suspected H5N1 bird flu, come out from their house in Sukur village near Peshawar, Pakistan on Saturday, Dec. 15, 2007. Six people caught H5N1 bird flu in northern Pakistan last month and at least one person with the disease has died, the government said Saturday. The U.N. World Health Organization confirmed the deadly H5N1 strain was found in the six cases, but said a second round of tests were being carried out to make sure. (AP Photo/Mohammad Zubair)
The story is also incorrect because Tariq is not one of the brothers who died. He is shown alive and breathing on December 16th in a wire service photo with his surviving brother Ishtiaq, the verterinarian.
Several sources reported one death on Nov 19th, which happened to fall on a Monday. I suspect these are recycled articles.
__________________
"In the beginning of change, the patriot is a scarce man (or woman), and brave, and hated and scorned. When his cause succeeds, the timid join him, for it then costs nothing to be a patriot."- Mark Twain Reason obeys itself; and ignorance submits to whatever is dictated to it. -Thomas Paine
The story is also incorrect because Tariq is not one of the brothers who died. He is shown alive and breathing on December 16th in a wire service photo with his surviving brother Ishtiaq, the verterinarian.
GENEVA (Reuters) - The World Health Organisation (WHO) suspects there has been only limited human-to-human transmission of the H5N1 virus in Pakistan, but international test results are still pending, a top official said on Friday.
David Heymann, WHO assistant director-general for health security and environment, also said that no new suspect human bird flu cases had emerged in Pakistan since December 6, signaling there had been no further spread.
Global health experts fear that bird flu could mutate into a form that spreads easily from one person to another, triggering a pandemic that could kill millions of people.
Pakistan announced last week that 8 people had been infected since late October, including a veterinarian involved in culling whose two brothers died. A WHO team has investigated the outbreak, and international laboratory results on samples taken are now expected at the weekend.
"The team feels that this could be an instance of close contact human-to-human transmission in a very circumscribed area and non-sustained, just like happened in Indonesia and Thailand," Heymann told a news briefing in Geneva.
In Thailand, a mother was killed by the virus in 2004 after cradling her dying infected daughter all night. The largest known cluster of human bird flu cases worldwide occurred in May 2006 in the Karo district of Indonesia's North Sumatra province, where as many as 7 people in an extended family died.
Keiji Fukuda, coordinator of WHO's global influenza program, told Reuters in an interview on Tuesday the cases in Pakistan are probably a combination of infections from poultry and limited person-to-person transmission due to close contact from caring for a sick loved one.
.
__________________
"The next major advancement in the health of American people will be determined by what the individual is willing to do for himself"-- John Knowles, Former President of the Rockefeller Foundation
Re: Pakistan: December 18+, WHO Begins Investigations
Pakistan urges safer culling after bird flu outbreak
ISLAMABAD: The government is urging provincial authorities to obey health guidelines to prevent any bird flu outbreaks after eight people were recently infected with the H5N1 virus. The Health Ministry is sending out messages via radio and pamphlets to NWFP, where South Asia’s first cases of human infections occurred. “These winter months are critical,” Federal Health Secretary Khushnood Akhtar Lashari said on Thursday. He said provincial authorities were requested to adhere to safety guidelines but it was difficult because of the remote areas. A WHO report on the situation is due soon. reuters
Courtesy DailyTimes.com.pk
Re: Pakistan: December 18+, WHO Begins Investigations
Dec 21, 10:05 AM EST
WHO: limited human-to-human bird flu transmission possible in Pakistan, no current threat
By MARGIE MASON
AP Medical Writer
Limited human-to-human bird flu transmission may have occurred in Pakistan, but no new infections have been reported for two weeks and there appears to be no threat of further spread, a top World Health Organization official said Friday.
A WHO team has finished its initial investigation in Pakistan after up to nine patients, including several family members, were suspected of being infected with the H5N1 bird flu virus in areas north of Islamabad. They were the country's first reported human cases.
The experts were expected back in Geneva to begin piecing together how the virus may have spread, but they found no evidence of anyone currently sickened by the virus, Dr. David Heymann, the WHO's top flu official in Geneva, told The Associated Press by telephone.
"I think the team right now feels on initial analysis that this might be a small chain of human-to-human, non-sustained transmission," he said, stressing that there was no cause for alarm.
He said the last reported case was on Dec. 6. Pakistani health officials have conducted initial testing on the samples, and found them to be positive, but WHO has sent the specimens to one of its collaborating laboratories for confirmation.
At least 209 people have died worldwide 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.
Most cases have been linked to contact with infected birds, but scientists believe limited human-to-human transmission has occurred a few times before among blood relatives who had close contact.
Five brothers were sickened last month in the small city of Abbotabad, about 50 kilometers (30 miles) north of Islamabad. One was a veterinarian who was involved in slaughtering sick poultry infected with bird flu. Two of his brothers fell ill and died, one of whom was buried before tests were conducted. The veterinarian and his other two brothers recovered.
Up to five other people in the same area also tested positive for the virus in preliminary tests.
Heymann said no one knows when a pandemic will occur or what virus will start it, but countries need to be prepared to take action.
"The more it reproduces, whether it's in humans or chickens, the more likely there is that there's an event that will occur that causes it," he said. "We just have to wait to see what's going to happen."
Meanwhile, Indonesia, which is the world's hardest-hit country with 93 human deaths, also reported Friday that five people from an extended family had been hospitalized with flu-like symptoms in an area where bird flu was earlier reported in poultry. Specimens have been taken to determine whether any of the relatives were infected with the H5N1 virus.
Myanmar reported its first human case last week and a number of other countries have recently reported poultry outbreaks during the winter months when the virus typically flares.
----
Margie Mason covers medical issues across the Asia-Pacific region.
Re: Pakistan: December 18+, WHO Begins Investigations
WHO says only limited human H5N1 spread in Pakistan
21 Dec 2007 15:10:33 GMT
Source: Reuters
(Adds China, quotes, background)
By Stephanie Nebehay
GENEVA, Dec 21 (Reuters) - The World Health Organisation (WHO) suspects there has been only limited human-to-human transmission of the H5N1 virus in Pakistan, but international test results are pending, an official said on Friday.
David Heymann, WHO assistant director-general for health security and environment, said no new suspect human bird flu cases had emerged in Pakistan since Dec. 6, signalling there had been no further spread.
Global health experts fear the virus could mutate into a form that spreads easily from one person to another, triggering a pandemic that could kill millions of people.
Pakistan said last week 8 people had been infected since late October, including a veterinarian involved in culling whose two brothers died. A WHO team has investigated the outbreak and international laboratory results on samples taken are expected at the weekend.
"The team feels that this could be an instance of close contact human-to-human transmission in a very circumscribed area and non-sustained, just like happened in Indonesia and Thailand," Heymann told a news briefing in Geneva.
HUMAN INFECTIONS
In Thailand, a mother was killed by the virus in 2004 after cradling her dying infected daughter all night. The largest known cluster of human bird flu cases worldwide occurred in May 2006 in the Karo district of Indonesia's North Sumatra province, where as many as 7 people in an extended family died.
But in China, it would never be clear whether a father who developed the disease days after his son died from it this month was due to contamination or common exposure to infected poultry, he said. This was because both conditions had existed -- close contact between the pair as well as sick chickens in the eastern province of Jiangsu.
Even if the disease had spread from the son to the father, it had stopped there, according to Heymann. Blood samples taken from 600 of their contacts had not shown antibodies, a sign that would have indicated the virus was circulating widely.
"So this remains a zoonotic (animal) disease, which under very intimate contact of some type -- whether it is touching a person and getting the virus on your finger and then getting it into your eye or mouth, it's not clear -- on occasional instances can be transmitted," Heymann said.
In Pakistan, the investigation had shown there were "no active suspect cases at present", he added.
He said Indonesia, the nation worst hit by bird flu with 93 deaths, had not shared bird flu samples since those from two Indonesian women who died in the resort of Bali in August.
It was the only country not to share samples, which are vital for tracking the virus and developing diagnostic tests as well as vaccines against a pandemic, he added.
Indonesia is seeking a guarantee that developing nations will have control over the use of samples and access to affordable vaccines derived from them.
Negotiations among the WHO's 193 members will continue next year on a system for sharing samples which would offer equitable access to vaccines, according to Heymann. (Editing by Jonathan Lynn)
The World Health Organisation (WHO) suspects there has been only limited human-to-human transmission of the H5N1 virus in Pakistan, but international test results are still pending, a top official said on Friday.
David Heymann, WHO assistant director-general for health security and environment, also said that no new suspect human bird flu cases had emerged in Pakistan since December 6, signaling there had been no further spread.
The above comments from WHO raise additional concerns about the human to human (H2H) transmission in Pakistan. Although media reports have described two H5N1 fatalities in a large familial cluster, the number of additional reported cases continues to grow. The above statement indicates new cases have been confirmed this month by NAMRU-3, which contradicts statements made yesterday by the Pakistan Ministry of Health that the last case was November 23.
Many of the cases appear to be mild, which limits detection and contact tracing. Testing of patients after they have been given prophylactic oseltamivir (Tamiflu) also limits detection. However, even with these limitations, new cases are being identified. It remains unclear if these new cases extend the transmission change, which would appear to be the longest and most sustained reported to date for H5N1.
The index case for the longest chain developed symptoms October 25, and two brothers died November 19 and November 29. New cases this month may extend this chain further. Earlier reports described a female health care worker who had tested positive. A male doctor was also hospitalized with symptoms at the same hospital that treated the index case as well as the two fatal cases. It remains unclear if the positive patients this month included the two previously mentioned health care workers, but if they are confirmed, it seems likely that the transmission chain has been sustained for at least six weeks.
Media reports indicated the initial lab positives were confirmed last Saturday in Pakistan.
The absence of a WHO situation update, detailing age, gender, disease onset dates, hospital admission dates, dates of death, and the relationship between confirmed cases remains a cause for concern.
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__________________
"The next major advancement in the health of American people will be determined by what the individual is willing to do for himself"-- John Knowles, Former President of the Rockefeller Foundation
Limited human-to-human bird flu transmission may have occurred in Pakistan, but no new infections have been reported for two weeks and there appears to be no threat of further spread, a top World Health Organization official said Friday.
A WHO team has finished its initial investigation in Pakistan after up to nine patients, including several family members, were suspected of being infected with the H5N1 bird flu virus in areas north of Islamabad. They were the country's first reported human cases.
The experts were expected back in Geneva to begin piecing together how the virus may have spread, but they found no evidence of anyone currently sickened by the virus, Dr. David Heymann, the WHO's top flu official in Geneva, told The Associated Press by telephone.
Most cases have been linked to contact with infected birds, but scientists believe limited human-to-human transmission has occurred a few times before among blood relatives who had close contact.
Five brothers were sickened last month in the small city of Abbotabad, about 50 kilometers (30 miles) north of Islamabad. One was a veterinarian who was involved in slaughtering sick poultry infected with bird flu. Two of his brothers fell ill and died, one of whom was buried before tests were conducted. The veterinarian and his other two brothers recovered.
Up to five other people in the same area also tested positive for the virus in preliminary tests.
The above comments perpetuate a number of media myths concerning human to human H5N1 transmission. The myths are clearly contradicted by WHO confirmed cases. These statements have no scientific basis, but the propagation by the popular press continues.
Although WHO has yet to put out a detailed situation update on the confirmed cases, a consensus from media reports strongly suggests that this is the longest and most sustained H5N1 infection reported to date. The longer chain appears to involve five brothers and a cousin, as well as one or two health care workers. Media reports indicate the index case developed symptoms on October 25. Two brothers were fatally infected after visiting their brother in the hospital. The two brothers died November 19 and 29. Media reports suggest two health care workers also tested positive or had bird flu symptoms and appear to be affiliated with the same Kyhber Teaching Hospital that treated several family members.
The health care workers, who are unlikely to be blood relatives, are not the first unrelated members of a cluster. A family of five in Haiphong, Vietnam was confirmed H5N1 positive. The husband and wife were both positive. Another cluster in Vietnam included a brother and sister, a confirmed health care worker, and an unconfirmed health care worker with symptoms. A cluster in Azerbaijan included a friend in addition to family members.
However, in addition to clusters involving contacts who were not blood relatives, there have been many clusters involving family members with disease onset dates with gaps of 5-10 days. Many of the earlier clusters in Vietnam and Thailand were documented in a peer reviewed publication authored by WHO consultants.
Similar peer reviewed publications by WHO consultants have describe three likely H2H clusters in Indonesia in 2005, as well as the Azerbaijan cluster in 2006. These clusters were in addition to the Karo cluster in Indonesia in 2006 and the cluster in Thailand in 2004.
Most clusters involve two family members, and in many instances samples are not collected from the index case prior to death. In other instances, such as the many clusters in Turkey, the samples that were H5N1 positive in local testing in Turkey, were not confirmed after shipment to a WHO reference center in Mill Hill, England. The pairing of the positives in Turkey strongly suggested the positives were true positives, and the reduction of 21 positives in Turkey to 12 positives in Mill Hill was due to sample degradation. Moreover, sequences from only four isolates from the 12 positives were released, providing additional evidence for sample degradation and false negatives.
The number of H5N1 human clusters has been large, and most clusters have gaps in disease onset dates.
These growing transmission chains provide additional evidence for a more efficiently transmitted H5N1 that is not linked to genetic factors.
The latest cluster is almost certainly linked to the Qinghai clade 2.2 sub-clade, which has PB2 E627K fixed, which allows the H5N1 to replicate more efficiently at lower temperatures. Human clusters in 2006 and 2007 have additional changes in the receptor binding domain (including S227N, N186K, N186S, Q196R, V223I, M230I) , which would also facilitate a more efficient transmission.
Changes in the receptor binding domain many play a role in the current extended cluster. Sequence data on the cases and clusters in Pakistan would be useful.
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__________________
"The next major advancement in the health of American people will be determined by what the individual is willing to do for himself"-- John Knowles, Former President of the Rockefeller Foundation
Re: Pakistan: December 18+, WHO Begins Investigations
Pakistan H5N1 situation stable as Indonesia reports possible cluster
Robert Roos News Editor
Dec 21, 2007 (CIDRAP News) – The World Health Organization (WHO) said today there has been no evidence of more cases of H5N1 avian influenza in the wake of a recent case cluster in Pakistan, as news services reported at least five suspected H5N1 cases in an Indonesian family.
WHO officials in Geneva said no more H5N1 cases have been identified in the area of Abbotabad in northern Pakistan, where the cluster was reported last weekend. Results of confirmatory tests in the eight cases are still awaited, they told CIDRAP News.
Keiji Fukuda, coordinator of the WHO's global influenza program, told Reuters this week that the Pakistan cases probably represent a mix of poultry-to-human infections and human-to-human transmission resulting from close contact when people cared for infected relatives.
"We don't have any indication of a broader health threat, other than poultry outbreaks" in the area, WHO spokesman John Rainford told CIDRAP news today. "Our risk assessment suggests no evidence of sustained transmission. All the close contacts and involved healthcare workers remain asymptomatic and have been released from close medical observation."
The WHO sent a team of experts to Pakistan to help investigate the situation, and US Navy Medical Research Unit 3 (NAMRU-3) in Cairo has sent a portable laboratory.
Rainford declined to predict today how soon confirmatory testing in the eight cases, which were identified in preliminary tests by Pakistan's national lab, will be completed. He said some samples from the patients would be sent to London for analysis.
"I hope we'll get some early results but question whether we'll have lab results that are what we need," he said. "We've got, hopefully, samples arriving in London sometime over the weekend that will provide a better environment to assess what we've got."
He said he expected both the NAMRU lab and the one in London will play a role in the testing: "NAMRU staff on site will be able to give us some information, but I guess there's a role for an additional lab to give us a full picture."
The patients who tested positive include four brothers in one family, one of their cousins, and two other people, according to news reports. The family group was originally described as four brothers and two cousins, but one patient initially identified as a cousin was actually a brother, the Associated Press reported on Dec 21. One of the four brothers died, and a fifth brother also was suspected of having the disease but died without being tested. The other three people were described as a man and his niece who were involved in culling poultry in connection with avian flu outbreaks, and a male farm worker from another town nearby.
WHO spokesman Gregory Hartl told CIDRAP News today that all of the surviving case-patients have recovered, adding, "I believe that all of them have also been released from hospital."
Meanwhile, five members of a family from Indonesia's West Java province have been hospitalized with suspected H5N1 cases, according to news reports citing Indonesia's state news agency, Antara, as their source.
A man named Fathurahman told Antara that his three children, aged 8, 10, and 16, suffered from high fevers, coughing, and breathing difficulty after an H5N1 outbreak among local poultry, according to a report by the Straits Times, a Singapore newspaper.
The three children and two other people in their extended family—siblings aged 17 and 30—were hospitalized in Serang, about 80 kilometers west of Jakarta, early this week, the story said. They were transferred today to Persahabatan Hospital in Jakarta, which is designated to treat avian flu patients, the report said.
A Xinhua report today said avain flu was suspected in the patients after health officials learned that 60 chickens and ducks in their village had died of H5N1 disease.
Two more members of the same family have also had symptoms suggesting avian flu but have not been hospitalized, the Straits Times reported.
In other developments, WHO officials said they will never know whether the recent H5N1 cases in a son and father in China involved person-to-person transmission. The patients were a 24-year-old man who died Nov 27 and his father, who was hospitalized with an H5N1 infection 6 days later.
David Heymann, the WHO's assistant director-general for communicable diseases, said today that the possibility of person-to-person transmission can never be confirmed or excluded, because the father and son had a common environmental exposure, Hartl told CIDRAP News.
Hong Kong newspapers reported earlier this month that before falling ill, the two men had both eaten undercooked chicken at a restaurant in Nanjing, capital of Jiangsu province. See also:
Dec 17 CIDRAP News story "Possible H5N1 family cluster probed in Pakistan"
Dec 10 CIDRAP News story "Reports suggest common source in family H5N1 cases"
Re: Pakistan: December 18+, WHO Begins Investigations
No new bird flu infections in humans reported
AP
Published: December 22, 2007, 00:23
Geneva: Limited human-to-human bird flu transmission may have occurred in Pakistan, but no new infections have been reported for two weeks, a top World Health Organisation official said on Friday.
A WHO team has finished their initial investigation in Pakistan after up to nine patients, including several family members, were suspected of being infected with the H5N1 bird flu virus in areas north of Islamabad.
The experts were expected back in Geneva to begin piecing together how the virus may have spread, but they found no evidence of anyone currently sickened by the virus, said Dr David Heymann, WHO's top flu official in Geneva.
"I think the team right now feels on initial analysis that this might be a small chain of human-to-human, non-sustained transmission," he said, stressing that there was no cause for alarm.
__________________
"In the beginning of change, the patriot is a scarce man (or woman), and brave, and hated and scorned. When his cause succeeds, the timid join him, for it then costs nothing to be a patriot."- Mark Twain Reason obeys itself; and ignorance submits to whatever is dictated to it. -Thomas Paine
Re: Pakistan: December 18+, WHO Begins Investigations
WHO Says Spread of Bird Flu Among Humans Limited
By Lisa Schlein
Geneva 22 December 2007
The World Health Organization (WHO) says limited human-to-human transmission of the H5N1 avian influenza virus may have occurred in Pakistan. But it says the threat of further spread appears to have stopped as no new infections have been reported for two weeks. Lisa Schlein reports for VOA from WHO headquarters in Geneva.
Hospital staff clean and disinfect room in isolation ward where bird flu patient was treated in Abbotabad, Pakistan, 17 Dec 2007
Assistant Director-General of the World Health Organization and top bird flu expert, Doctor David Heymann, says a team of WHO experts has completed an investigation into an outbreak of bird flu in Pakistan. He says tests were carried out among a group of people who became infected with the deadly H5N1 strain of the virus in October.
Doctor Heymann says an analysis of the information is not yet complete. But preliminary results indicate there was human-to-human transmission of the virus. He says there could have been a common source of the infection.
"The team feels, we have not seen all their evidence yet, but they feel that this could be an instance of close contact of human-to-human transmission in a very circumscribed area and not sustained," he explained. "Just like happened in Indonesia and in Thailand."
Nine people, including five brothers, became infected with the H5N1 bird flu virus in a small town north of Islamabad. One was a veterinarian involved in culling sick poultry. Two of his brothers fell ill and died. The veterinarian and his other two brothers subsequently recovered.
Doctor Heymann says H5N1 remains an animal disease. He says there have been only occasional instances where human-to-human infections have occurred.
The World Health Organization reports at least 209 people have died worldwide from the virus, most in Indonesia. Scientists fear the H5N1 or another as yet unidentified virus could mutate into a form that could easily spread the disease among humans.
Doctor Heymann says there were three avian flu pandemics in the last century and other pandemics before then. He says there is a clear understanding in the scientific community that there will be another pandemic of influenza.
"We do not know what virus will cause that, but we know there are avian influenza viruses out there and those viruses could cause a pandemic eventually," he explained. "As long as H5N1 is circulating anywhere in the world, there is a chance that that virus can, either through an adaptive mutation or re-assortment, cause a pandemic. The problem is nobody can quantify that risk."
Doctor Heymann says countries have to be prepared to take action when a pandemic strikes. He says the World Health Organization is stockpiling H5N1 vaccines.
He says they would be used to vaccinate essential populations, such as health workers and security forces, in countries where the pandemic is starting. He says the vaccines also would be used to vaccinate people in areas surrounding a contaminated zone to try to contain the virus and stop it from spreading.
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Re: Pakistan: December 18+, WHO Begins Investigations
), and brave, and hated and scorned. When his cause succeeds, the timid join him, for it then costs nothing to be a patriot."- Mark Twain
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