Published Date: 2003-04-19 23:50:00
Subject: PRO/AH/EDR> Avian Influenza, human - Netherlands (09): fatal case
Archive Number: 20030419.0959
AVIAN INFLUENZA, HUMAN - NETHERLANDS (09): FATAL CASE
A ProMED-mail post
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International Society for Infectious Diseases
Date: Sat, 19 Apr 2003
From: R.A.M. Fouchier <firstname.lastname@example.org>
H7N7 in The Netherlands; first fatal human case
A 57-year-old veterinarian who visited a poultry farm affected by
HPAI H7N7 infection (in Teefelen) died on 17 Apr 2003, as the result
of acute respiratory distress syndrome (ARDS) and related
complications in a hospital in 's Hertogenbosch [Den Bosch], The
On 4 Apr 2003, the veterinarian suffered from a high fever and severe
headache without additional symptoms. On 8 April, when he first
visited his family doctor for persisting fever, no signs of
respiratory disease were observed and consequently he did not receive
medication. Because he reported to have worked as a poultry
veterinarian and had visited a farm affected by HPAI H7N7 on 2 Apr
2003, a throat swab and an eye swab were collected on 9 April and
sent to the National Influenza Centre (NIC) for influenza A virus
(H7N7) diagnostics. RT-PCR tests performed in 2 laboratories were
both negative. These tests are routinely performed in the framework
of the surveillance of A/H7-associated-illness in poultry workers
during this epizootic [see ref 20030316.0656].
On 11 Apr 2003, the man was admitted to hospital because of suspected
pulmonary involvement, where he was diagnosed with bilateral
pneumonia. He was moved to the intensive care unit a day later with
deteriorating condition and was put on mechanical ventilation. On 14
Apr 2003 his renal function decreased and dialysis was started.
Further deterioration was observed on 15 April, thorax X-rays
revealing bilateral interstitial pneumonia. He was treated with
doxycycline and ofloxacin. A bronchoalveolar lavage (BAL) was
performed for diagnostic purposes. He died on 17 Apr 2003.
The BAL sample was sent to the NIC, where a high virus load of
influenza A (H7) virus was found, using a real-time PCR assay
specific for the matrix and haemagglutinin genes. Testing for other
respiratory viruses and bacteria are so far negative. In throat swabs
collected on 11 and 13 Apr 2003 and sent to another laboratory, the
presence of herpes simplex virus was indicated -- for which he was
treated with Aciclovir.
Postmortem specimens of the right and left lung were collected and
also sent to the NIC. PCR analysis of these samples confirmed the
presence of H7 influenza A virus. Serum samples collected on 11 and
17 April displayed a slight increase in H7-specific antibodies in
haemagglutination inhibition [HI] assay. This result needs to be
confirmed in additional serological tests.
Since the beginning of the HPAI H7N7 outbreak in chickens in The
Netherlands at the end of February 2003, 82 confirmed cases of human
H7N7 influenza virus infections have been recorded. The majority (79)
of these cases presented with conjunctivitis, of which in 6 cases
influenza-like illness (ILI) were reported as well. One person had
ILI alone but suffered an eye injury, precluding evaluation for the
typical ocular signs of infection. The other 2 individuals presented
with very mild symptoms and could not be classified as conjunctivitis
We have found strong evidence for transmission of H7N7 influenza from
poultry workers to family members on 3 occasions. These contacts
developed conjunctivitis. One of them, a 12-year-old child, had
significant ILI as well and was repeatedly positive for A/H7.
This first death of a previously healthy individual, for which H7N7
HPAI is the most likely cause, demonstrates that the HPAI outbreak in
chickens, due to frequent transmission to humans and probably pigs,
is a major concern to public and animal health. Protective measures
in humans that are in close contact with infected animals
(vaccination against human influenza and prophylactic treatment with
antivirals) and culling of affected chicken flocks and pigs is of
utmost importance to control this outbreak. Most poultry workers that
were diagnosed with A/H7 in the past 2 weeks have been non-compliant.
The importance of stringent control is underscored by the fact that
A/H7 infections have been detected in poultry workers that had been
recruited from other countries, beyond reach of the public health
authorities involved in the containment of this outbreak.
It is important to note that in the intensive monitoring that is
currently implemented, no co-infections with H7N7 and human influenza
A viruses have been detected so far. To date, no significant genetic
changes have been observed in virus isolates from humans, including
the  human-to-human transmission cases. The neuraminidase
subtyping and genetic analysis of the influenza A virus detected in
the deceased veterinarian will be important in determining whether
this is a "normal" avian influenza virus or one with distinct genetic
and biological properties.
Ron Fouchier, Thijs Kuiken, Gerard van Doornum, Marion Koopmans and
Ab Osterhaus, National Influenza Centre, Bilthoven/Rotterdam, The
Ron A.M. Fouchier, PhD
3015 GE Rotterdam
Date: Sat, 19 Apr 2003
From: Stephen M. Apatow <email@example.com>
Source: Reuters, 19 Apr 2003 [edited]
Dutch vet's death linked to bird flu virus
A Dutch veterinarian has died of pneumonia after catching the poultry
disease bird flu, officials said on Saturday, raising fears that a
mutated version of the virus could cause a SARS-type epidemic in
The 57-year-old man died on Thursday in the southern city of Den
Bosch, the Health Ministry said. He fell ill 2 days after working on
a farm infected with bird flu, or avian virus.
The World Health Organisation has warned that the disease could turn
into a human epidemic, at a time when deadly Severe Acute Respiratory
Syndrome (SARS) is sweeping the globe.
The Dutch have been grappling for a month to contain the bird flu
outbreak that has spilled into Belgium and is nearing Germany, amid
concerns that bird and human flu could mix in pigs and produce a
mutation that humans have no resistance against.
Scientists stressed on Saturday that preventative measures were in
place, including guidelines for at-risk workers to take medication
against bird flu and human flu. Transport restrictions have been
introduced for pigs after several animals were found to have
antibodies to bird flu, and millions of birds have been slaughtered.
The veterinarian who died had not taken antiviral medication.
"This was a very unusual situation," the Health Ministry said in a
statement. "Because the bird flu virus was detected in the lungs and
there is no other possible clinical explanation, there are strong
indications that the man died as a result of the bird flu virus."
Scientists at Erasmus Medical Center in Rotterdam identified the
virus in the veterinarian's lungs as part of the same H7 family as
the bird flu virus, Dr Albert Osterhaus, who heads the virology
department, told Reuters.
Staff were now working on further [genetic] sequencing to see whether
any mutations had occurred, said Osterhaus. "The doom scenario would
be if animals or humans became infected with human and animal viruses
and there was an exchange of genetic material," Osterhaus said. "The
result would be a (new) virus against which there would be no
immunity in the population."
The chances of this happening were small, however, and measures
already in place should prevent it happening, he added.
The "Asian flu" and "Hong Kong" pandemics of 1956-1957 and 1967-1968,
caused by new influenza strains, killed a combined 4.5 million people.
"Up to now avian flu has never acquired the ability to transmit from
one person to another -- if it does it could cause a large number of
infections," World Health Organisation spokesman Iain Simpson told
Reuters earlier this week. "There have been a number of influenza
pandemics over the centuries, and the last one was in the late 1960s,
so there is a view that we're overdue another one although that
doesn't mean it's going to happen any time soon."
Bird flu had already infected a handful of farm workers. Most only
suffered minor eye infections that were relatively harmless and
easily treated. A couple had influenza symptoms, but those cases were
treated successfully, Osterhaus said.
SARS, which has killed 172 people and infected nearly 3500 around the
world, [is caused by a] coronavirus, a completely different family,
one of which also causes the common cold. "The only similarity is
that it is a virus that spills over from an animal reservoir...but
what allowed that virus to cross the species barrier we have no
idea," said Osterhaus, whose team was among global researchers who
pinpointed the SARS virus.
Some people say SARS might have been the result of human and avian
viruses mixing in Guangdong, China, where people live close to
animals, but Osterhaus said this is just speculation.
[Byline: Eric Onstad]
[We are very grateful for the first-hand, authoritative, and detailed
report of Dr Fouchier and his NIC colleagues.
In addition to the worrisome "most likely" possibility that this
tragic case was directly and solely caused by the H7N7 virus, there
is another cause for grave concern -- namely the "strong evidence"
for 3 human-to-human infections of the said virus.
The expert team's remark on the "utmost importance" of pig culling is
significant; as reported earlier, so far only avians have been
culled, while steps related to the culling of pigs seem to be under
consideration by the Ministry of Agriculture (see ref 20030418.0950).
Some press items tend to confuse SARS and Avian Influenza,
occasionally speculating that SARS is also caused by a mutated avian
virus. Prof Osterhaus' explanatory remark is timely. - Mod.AS]