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Human-to-human spread suspected in latest Indonesian bird-flu death

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  • Human-to-human spread suspected in latest Indonesian bird-flu death

    http://www.macleans.ca/topstories/ne...ntent=w052249A
    May 22, 2006 - 19:15
    Human-to-human spread suspected in latest Indonesian bird-flu death
    HELEN BRANSWELL

    The World Health Organization appears to be edging closer to suggesting that an Indonesian man who died from H5N1 avian flu Monday may have been infected by his 10-year-old son, not through exposure to sick poultry or some other environmental source.

    WHO officials had earlier expressed the theory that a thorough investigation might reveal a potential source of contagion in the community, such as use of contaminated chicken feces as manure. But expert disease investigators seem to be ruling out that possibility, a spokesperson for the WHO said from Geneva.

    "There's no supporting evidence to suggest that this is a continuing environmental source that we've uncovered yet in the investigation," said WHO spokesperson Dick Thompson.

    "The investigation is still ongoing. We wouldn't discount the possibility that it is human-to-human transmission."

    Limited spread of the virus among people is believed to have happened on several previous occasions. But in each of these suspected cases, transmission of the virus petered out. Sustained human-to-human spread of the virus would be needed to trigger a pandemic.

    Meanwhile, an Indonesian official revealed that the man who died Monday refused treatment and fled from authorities after falling ill - behaviour that highlights the difficulties of disease containment in settings where an unfamiliar disease is extracting a high death toll.

    "This is precisely what we see, time and time again," medical anthropologist Barry Hewlett, a veteran of a number of WHO missions to contain outbreaks of Ebola virus in Africa, said of the panicked reactions Indonesian media have reported.

    Reports have suggested fear and distrust have been running high in the affected community, which has watched in horror as multiple members of an extended family fell gravely ill in recent weeks, with most dying.

    Dr. Heinz Feldmann of the Public Health Agency of Canada's National Microbiology Laboratory said in his experience fighting outbreaks of diseases like Ebola and Marburg fever, panic and distrust of authorities and medical outsiders is exacerbated when the death toll starts to rise.

    "There are these white doctors who come in. Everyone thinks they're getting help, and then they're realizing they're not getting help. And everyone who goes into isolation (in hospital) is basically dying or a lot of them are dying," said Feldmann, a leading expert on hemorraghic fevers who heads the Winnipeg lab's special pathogens division.

    "Then the community turns against you."

    In cases dating back to late April, three of the man's siblings, two nephews, and two of his children became infected with the H5N1 virus. Only one family member who fell ill, a brother, has recovered from the infection.

    The man's older sister, believed to be the first case in this cluster, died without being tested and is not on the WHO's official case count. With this latest case, the number of confirmed H5N1 cases in this family rises to seven, with six deaths.

    The man, 32, is said to have nursed his son while the boy was dying, putting him in the path of blasts of virus-laced droplets.

    When he himself became ill, he evaded authorities, the director-general of communicable disease control for the Indonesian health ministry told a news conference Monday.

    "He ran away after he received Tamiflu," said I. Nyoman Kandun. "He was found in the village later but refused treatment."

    Both Hewlett and Feldmann said getting people in such settings to co-operate with public health officials is a significant challenge that requires lots of communication with the community, sensitivity and a willingness to try to figure out what is motivating the behaviour.

    Hewlett, a professor at Washington State University in Vancouver, Wash., recalls seeing Ugandans fleeing ambulances during a major Ebola outbreak in that country in 2000.

    It turned out that there were rampant rumours that the team wasn't fighting disease, but was kidnapping Ugandans for body parts. The urban myth was fuelled by the fact that family members weren't allowed to visit their loved ones during their illnesses or after their deaths because of the fear of further spread of disease.

    "My point is simply that you need to work with local people if you're going to make these things successful. Otherwise there's going to be resistance and the outbreaks will get worse rather than get better," said Hewlett, adding the WHO often now includes medical anthropologists or psychologists on outbreak teams as "social mobilizers" who can bridge the divide between the people affected and medical experts.

    Feldmann said he can see another possible source of conflict with the Indonesian villagers - the fact that H5N1 control requires the culling of affected poultry. Demanding people give up animals they need, and which they often don't believe are a source of infection, can create tension, he suggested.

  • #2
    Re: Human-to-human spread suspected in latest Indonesian bird-flu death

    <TABLE cellSpacing=0 cellPadding=0 width=635 border=0><TBODY><TR><TD>http://www.bloomberg.com/apps/news?p...top_world_news
    Bird Flu Tally Climbs as Scientists Consider Human Transmission
    May 23 (Bloomberg) -- The number of reported bird flu fatalities this month climbed to 13, the highest since February 2004, as scientists investigate whether the virus has undergone changes enabling it to spread more easily between people.

    Limited human-to-human transmission can't be ruled out as the cause of infection in seven members of an Indonesian family found with avian influenza this month, Indonesia's Ministry of Health said yesterday. Six of the people died. Investigators haven't found infected poultry or pigs near where they lived.

    ``An extremely high priority should be to determine whether the virus has undergone any significant genetic changes,'' Jennifer McKimm-Breschkin, a virologist at Australia's Commonwealth Science and Industrial Research Organization (CSIRO) in Melbourne, said in a phone interview today.

    Any evidence that the lethal H5N1 strain of avian flu has increased its ability to spread among humans may prompt the World Health Organization to consider raising its alert level for a human pandemic, a signal that a deadly outbreak of disease is increasingly likely.
    Officials from the WHO and the U.S. Centers for Disease Control and Prevention joined local authorities last week on the Indonesian island of Sumatra to try to pinpoint how the people became infected with H5N1 in the past month. Virus samples isolated from infected family members are also being analyzed.

    ``With no animal identified as yet as the source of infection, this cluster raises the suspicion of human to human transmission,'' McKimm-Breschkin said. ``It warrants further urgent investigation, especially of people who may have come into contact with the infected people.''

    No Immunity

    Fear of a human spread of H5N1 is running high, in part because it is so lethal to people who have no natural immunity to the virus, which has killed two-thirds of those confirmed to be infected this year.

    Since late 2003, the virus has sickened 217 people in 10 countries, killing 123 of them according to the WHO's May 19 count. In February 2004, the WHO confirmed 12 fatalities in Vietnam and seven in Thailand. The tally excludes a 32-year-old man from the Sumatran family who died yesterday, more than a week after his 10-year-old son.

    Indonesia's Ministry of Health yesterday said local tests confirmed that a 38-year-old woman from Surabaya, in East Java, died from the virus on May 12, and a 38-year-old man in Jakarta died on May 19. An 18-year-old man who had been working in a factory making shuttlecocks for badminton tested positive and is alive, it said.

    Cases in Iran

    A woman and her husband are suspected to have died of avian flu in Iran, the ISNA news agency reported yesterday, citing Dr. Izadi, a health official in the northwestern province of Kermanshah. Two others have been hospitalized with avian flu-like symptoms, the report said.
    Almost all human H5N1 cases have been linked to close contact with sick or dead birds, such as children playing with them or adults butchering them or taking off feathers, according to the WHO. Thorough cooking of meat and eggs kills the virus.

    The WHO's pandemic alert now is at the third of six levels, indicating that a new flu virus subtype is causing disease in humans, though not yet spreading efficiently and in a sustainable way among people.

    To raise the alert by one level, the WHO would convene a panel of outside officials. The panel would make a recommendation to acting Director General Anders Nordstrom, who would then order the change.

    A WHO planning document that lists events that might cause the level to change includes: moderate or worse lung disease in five to 10 persons with evidence of human-to-human transmission in at least some and laboratory confirmation of H5N1 infection in at least two patients.

    Pandemic Alert

    Each of the six stages in the alert system triggers a series of recommended activities to be undertaken by the WHO, other international organizations, governments, and industries.

    Human flu viruses can normally spread in the air, through hand shaking or via contaminated surfaces. A mutation that allows H5N1 to spread that way among humans might set off a pandemic as deadly as one in 1918, called the Spanish flu, that killed an estimated 50 million people worldwide, or about 2.5 percent of the estimated number infected.
    </TD></TR><TR><TD>

    To contact the reporters on this story:Jason Gale in Singapore at j.gale@bloomberg.net;John Lauerman in Boston at jlauerman@bloomberg.net.</PRE></TD></TR></TBODY></TABLE>

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    • #3
      Re: Human-to-human spread suspected in latest Indonesian bird-flu death

      Commentary at

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      • #4
        Re: Human-to-human spread suspected in latest Indonesian bird-flu death

        http://www.recombinomics.com/News/05...e_4_Raise.html
        Commentary

        H5N1 Pandemic Increase to Phase Four?

        Recombinomics Commentary

        May 23, 2006

        In cases dating back to late April, three of the man's siblings, two nephews, and two of his children became infected with the H5N1 virus. Only one family member who fell ill, a brother, has recovered from the infection.

        The man's older sister, believed to be the first case in this cluster, died without being tested and is not on the WHO's official case count. With this latest case, the number of confirmed H5N1 cases in this family rises to seven, with six deaths.

        The man, 32, is said to have nursed his son while the boy was dying, putting him in the path of blasts of virus-laced droplets.

        The above information may be used as "proof" of human-to-human transmission of H5N1 (H2H) in North Sumatra, Indonesia, which could lead to the raising of the pandemic alert level to phase 4. Technically, the pandemic level has been at phase 4 or higher since early 2005. At that time the number of H5N1 clusters in northern Vietnam began to be reported at a greater frequency and the size of the clusters began to grow.

        However. WHO discounted most of these clusters because each bird flu cluster was analyzed individually, and most had a bird connection, which was used to discount the proof of H2H. When there are clusters of H5N1 cases, distinguishing a common source from the alternative explnation of H2H is heavily dependent on disease onset dates. By definition, clusters are two or more cases linked by time and space, so the sequence of the H5N1 usually does not provided conclusive evidence because the cases are closely related in time and a similar sequence would be expected regardless of source.

        However, since most cases develop symptoms 2-4 days after exposure, gaps of 5-10 days in disease onset dates suggests two or more independent infections. Since transmission from birds to humans is very rare, two independent infections in the same family is unlikely to be linked to birds. Family members have frequent contact with infected family member(s), and therefore transmission within families is far more common than transmission from a bird source to a human.

        Familial clusters were reported as early as the beginning of 2004 and the most cited case was in Thailand in August of 2004. The cluster has been cited as H2H because the mother of the index case was an office worker in Bangkok, far from her daughter who was on a farm with her aunt hundreds of miles away. The mother became infected after visiting her daughter in the hospital and the aunt was infect after the mother, supporting the infection of one or both by the index case. The adults did not develop symptoms until the daughter died, and the gap in disease onset dates was in the 5-10 day range.

        Most other clusters involved a potential bird source, so the "proof" was not conclusive. However, familial clusters accounted for about 1/3 of H5N1 cases in 2004 and early 2005 and almost all of the clusters had the 5-10 gap in onset dates.

        Thus, the clusters as a group provided overwhelming evidence for H2H. This evidence became stronger when H5N1 human cases in Indonesia began to be reported in July of 2005. Most cases were in clusters and overwhelming majority had the gap in onset dates.

        In 2006, larger clusters were being reported in Turkey and Azerbaijan, and these cluster had the same gap with evidence of growing transmission chains, including evidence for cluster-to-cluster transmission. The current cluster in North Sumatra may have the transmission chain increased to H2H2H2H, providing more proof of H2H, which may now cause an increase in the pandemic level because the concurrent cluster in Iran may be signaling a widespread increase in larger clusters in multiple regions by multiple versions of H5N1.

        The deployment of Tamiflu from the United Staes to Asia is another signal of a potentional pandemic phase increase.

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