ProMED-mail |

Published Date: 2008-01-10 23:50:00
Subject: PRO/MBDS> Avian influenza, human: China (Jiangsu), Pakistan, WHO
Archive Number: 20080110.0135

AVIAN INFLUENZA, HUMAN: CHINA (JIANGSU), PAKISTAN, WHO
***************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
In this posting:
[1] China - Jiangsu
[2] China - Jiangsu
[3] Pakistan - negative test, non-resident brother
[4] WHO timeline excerpts on issues related to
possible human to human transmission
******
[1] China - Jiangsu
Date: 10 Jan 2008
Source: China View / Xinhua Net [edited]
<http://news.xinhuanet.com/english/2008-01/10/content_7398344.htm>

China's latest human case of bird flu infected
through close contact with ill son
-----------------------
Health authorities confirmed here on Thursday [10
Jan 2008] that the latest human case of bird flu
in the eastern province of Jiangsu, which
involved a 52-year-old father, came from close
contact with his infected son and not a viral mutation.
The World Health Organization [WHO] has warned
that the virus that causes the illness -- if
given sufficient opportunity -- would mutate into
a form that is highly infectious and easily
transmissible from person to person. Such a
change could start a global outbreak. However,
this case -- although it involved the disease
apparently passing from one person to another --
does not exactly fit the profile of an infectious
human-to-human outbreak, and it has remained something of a puzzle.
"It has no biological features for human-to-human
transmission," said Mao Qun'an, Health Ministry
spokesman. An epidemiological investigation
showed the father was infected through close contact with his son, he said.
The cases took place in the provincial capital,
Nanjing. The son, 24, and the 1st to be infected,
died on [2 Dec 2007]. The father was later
confirmed to be infected with the H5N1 virus, which causes bird flu.
At the time, the ministry said experts had found
that the virus that infected the son had
originated with poultry and had not mutated. But
it remained unclear how the son was infected in
the 1st place, as neither man had any known
contact with dead poultry -- the primary known
source of the ailment for humans.
The young man, developed fever, chills and other
symptoms on [24 Nov 2007] and was hospitalized on
[27 Nov 2007] after being diagnosed with lower
left lobe pneumonia. His father developed a fever
and was hospitalized for lower lobe pneumonia on
[3 Dec 2007], the day after his son's death [2 Dec 2007].
"The father has recovered," Mao said, adding that
the cases have been effectively contained.
Local authorities had kept 83 people who had
close contact with either man under close
observation but none had shown unusual symptoms
so far, according to the ministry.
The case of the [above] family, although unusual,
is not the only one of its kind. Reuters reported
last month that a similar case occurred in
Pakistan [see part [3] below - Mod.MPP].
The latest cases bring the number of confirmed
human infections of bird flu in China to 27 since 2003, with 17 deaths.
A human-use bird flu vaccine has been in the 2nd
phase of clinical tests in Beijing by the
Beijing-based vaccine producer Sinovac Biotech
and the Chinese Center for Disease Control and Prevention.
[Byline: An Lu, editor]
--
Communicated by:
Dr. Yin Myo Aye
<yinmyoaye@gmail.com>
******
[2] China - Jiangsu
Date: 10 Jan 2007
Source: Bloomberg News [edited]
<http://www.bloomberg.com/apps/news?pid=20601087&sid=abAvvqq4Gp_A&refer=home>

Human Source of Bird Flu Likely in Latest China Cases
-----------------
Human-to-human spread probably occurred in
China's 2 most recent bird flu cases, a health ministry official said.
Preliminary findings of an investigation into the
cases involving a father and son in Nanjing city
in the eastern province of Jiangsu last month
[December 2007] indicated that "close contact"
was the most likely cause of their infection with
the H5N1 avian flu virus, ministry spokesman Mao
Qun'an said in a Webcast briefing from Beijing today [10 Jan 2007].
Human transmission wasn't sustained and the
outbreak was "brought under control effectively
and rapidly," Mao said. No diseased birds were
found near where the men lived, making it
difficult to determine an animal source. He said
the probability of person-to-person spread was
greater for the father, who developed fever on [3
Dec 2007], a day after his 24-year-old son died [2 Dec 2007].
Disease-trackers monitor clusters of 2 or more
linked cases to gauge whether the virus is
becoming adept at infecting humans, not just
birds. Millions of people could die if H5N1
develops the characteristics of seasonal flu and
begins spreading easily between humans through coughing and sneezing.
Evidence that the H5N1 virus is spreading easily
between people, including health-care workers,
could prompt the World Health Organization [WHO]
to raise its level of pandemic alert. The
agency's 6-phase alert system is at 3, indicating
a new influenza virus subtype is causing disease
in humans, but isn't spreading efficiently and sustainably among humans.
There was no biological evidence that the H5N1
strain that had infected the men in Nanjing more
closely resembled a human virus, and the
52-year-old father has recovered from his illness, Mao said.
No Dangerous Mutation
"Human-to-human transmission through close
contact between the son and the father cannot be
ruled out in this family cluster," said Hans
Troedsson, WHO's representative in China, in an
e-mail today. "However, the biological findings
at this stage show that the virus has not mutated
to a form that can be transmitted from human to human efficiently."
The source of the son's infection hasn't been
confirmed, Troedsson said. The 24-year-old
developed symptoms on [24 Nov 2007], was
hospitalized 3 days later and died on [2 Dec 2007].
"The possibility of animal-to-human infection
cannot be excluded" in the son's case, Troedsson said.
At least 348 people in a dozen countries have
contracted the virus since 2003. Out of every 5
cases, 3 were fatal and about a 10th of them
occurred in a cluster [?34 or 35 cases]. Most
cases were caused by contact with infected
poultry, such as children playing with them or
adults butchering them or plucking feathers, according to the Geneva-based WHO.
China has reported 27 human H5N1 infections, 17 of which were fatal.
[Byline: Zhang Dingmin]
--
Communicated by:
Dr. Yin Myo Aye
<yinmyoaye@gmail.com>
******
[3] Pakistan - negative test, non-resident brother
Date: 10 Jan 2007
Source: Canadian Press [edited]
<http://www.cbc.ca/cp/health/080109/x010906A.html>

Tests show US man, member of Pakistan bird flu family, never contracted virus
----------------------
Blood testing has confirmed that a U.S. resident
whose brother was Pakistan's 1st confirmed case
of H5N1 infection never contracted the disease.
The New York State health department revealed
that the man's blood showed no antibodies to
H5N1, indicating he had not caught the virus
while attending his brother's funeral in Pakistan late last year [2007].
"His final test came back. He showed no avian flu
and no antibodies to avian flu, which means he
never got it," Claudia Hutton, the department's
director of public affairs, said in an interview
from Albany, NY. The man, who lives on Long
Island, is part of a large family of brothers
involved in a cluster of confirmed, probable and
suspect cases. The other surviving brothers live
in Pakistan's North-West Frontier Province.
Because of the pattern of illnesses within the
family, the World Health Organization [WHO]
believes there was limited person-to-person
spread of the virus among the relatives. But
initial diagnostic efforts were only able to
confirm one case, so follow-up blood work will be
needed to determine how many people were actually infected.
One member of the family, a veterinary worker,
fell ill in late October [2007] after helping to
cull H5N1-infected poultry. While he was sick, at
least 2 of his brothers nursed him, 1st at home,
then at the hospital. The veterinary worker
survived but the 2 brothers died, one in
mid-November [2007] and the other on [ 28 Nov
2007]. The 1st man to die was never tested for
H5N1. But a specimen taken from the 2nd showed he
was infected with the virus. Another brother was
also ill and was hospitalized. Still another showed no signs of illness.
The brother from Long Island experienced mild
cold-like symptoms after returning from Pakistan.
And his young son, who did not make the trip with
him, also had a cold; it appeared to get worse after his father's return.
The man went to his doctor, the doctor notified
local public health authorities and they in turn
alerted the state. The U.S. Centers for Disease
Control even sent a plane to New York to collect
specimens from the man and his son for testing in the CDC's Atlanta labs.
They were both negative. But, a negative test
isn't proof positive there was no infection. A
test taken too late in the course of an infection could come back negative.
To close the book on the incident, authorities
collected blood samples from the man and the son
to look for the antibodies that would be present
if they had been infected with the virus. Both
the father and the son were negative in antibody testing.
The WHO said this week that blood samples from
the surviving family members in Pakistan have
been sent to a U.S. Naval laboratory in Cairo
that does influenza testing for the WHO. But it
could be a couple of weeks or longer before results are available.
[Byline: Helen Branswell]
--
Communicated by:
PRO/MBDS
<promed-mbds@promedmail.org>
******
[4] WHO timeline excerpts on issues related to
possible human to human transmission
Date: 2 Jan 2008
Source: WHO Avian influenza website [edited]
<http://www.who.int/csr/disease/avian_influenza/timeline2008_01_02.pdf>

With respect to reports of possible human to
human transmission, the WHO timeline of major
H5N1 avian influenza events available at the
above given URL has the following information:
1 Feb 2004 -- Investigation of a family cluster
of H5N1 cases, which occurred in Viet Nam in
early January [2004], cannot rule out the
possibility of limited human-to-human transmission.
18 Mar 2004 -- Case studies of 10 patients in
Viet Nam point to close contact with infected
poultry as the probable source of infection in
most cases, but conclude that, in 2 family
clusters, limited human-to-human transmission
within the family cannot be ruled out. (This
information came from Hien TT et al. Avian
influenza A (H5N1) in 10 patients in Vietnam. N
Engl J Med 2004; 350:1179�88. [available at
<http://content.nejm.org/cgi/content/full/350/12/1179>])
27 Jan 2005 -- Research concludes that a girl in
Thailand probably passed the virus to at least
her mother in September 2004, causing fatal
disease. This is the 1st published account of
probable secondary human transmission, resulting
in severe disease, of any avian influenza virus.
(This information came from Ungchusak K et al.
Probable person-to-person transmission of avian
influenza A (H5N1). N Engl J Med 2005; 352:4
333�40, [available at <http://content.nejm.org/cgi/reprint/352/4/333.pdf>])
30 Jun 2005 -- A WHO investigative team finds no
evidence that H5N1 has increased its transmissibility in humans in Viet Nam.
21 Jul 2005 -- Indonesia confirms its 1st human
case. Infection in 2 other family members is
considered likely, but cannot be laboratory
confirmed. Subsequent investigation is unable to
determine the source of infection. Virus has been
circulating in poultry in Indonesia since February 2004.
October 2005 -- Research on the evolution of
human and animal viruses circulating in Asia in
2005 suggests that several amino acids located
near the receptor-binding site are undergoing
change, some of which may affect antigenicity or
transmissibility. (This information came from
World Health Organization Global Influenza
Program Surveillance Network. Evolution of H5N1
avian influenza viruses in Asia. Emerg Infect Dis
Oct 2005; 11: 1515�21 [available at
<http://www.cdc.gov/ncidod/EID/vol11no10/05-0644.htm>].)
13 Feb 2006 -- China confirms its 12th case and
8th fatality. Some human cases have occurred in
areas with no reported outbreaks in poultry.
23 Mar 2006 -- Two research groups publish
findings that may help explain why the H5N1 virus
does not easily infect humans or -- like normal
seasonal influenza -- spread readily by coughing
or sneezing. Whereas human influenza viruses
attach themselves to molecules in cells lining
the nose and throat, avian viruses prefer to bind
to molecules located deep in the lungs. Such
findings are consistent with the clinical picture
of H5N1 infection, in which most patients present
with symptoms of infection in the lower
respiratory tract, with rapid progression to
pneumonia. (This information comes from Shinya K
et al. Influenza virus receptors in the human
airway. Nature 2006; 440: 435�36 [abstract
available at:
<http://www.nature.com/nature/journal/v440/n7083/full/440435a.html>]
and van Riel D et al. H5N1 virus attachment to
lower respiratory tract. ScienceExpress 23Mar
2006. Published online at:
<http://www.sciencemag.org/cgi/content/abstract/1125548>)
18 May 2006 -- Indonesia reports the largest
family cluster in any country to date, with 7
confirmed cases (the 34th through 39th and the
42nd) from 4 households in the Karo district of
North Sumatra. The index case (unconfirmed)
develops symptoms on 24 Apr [2006], the last case
dies on 22 May [2006]. Cases include the index
case's 2 sons, (aged 15 and 17 years), her
10-year-old nephew, her 2 brothers (aged 25 and
32 years), her 28-year-old sister, and this
sister's 18-month-old daughter. Disease does not
spread beyond the extended family. Limited human
to human transmission can not be ruled out.
Viruses do not show any significant genetic
mutations or reassortment. [note that all
affected family members in this cluster were
"blood relations" and none of the "married-in"
family members were affected, suggesting there
may be a genetic predisposition to the infection - Mod.MPP]
30 Jun 2006 -- The 1st analysis of
epidemiological data on all 205
laboratory-confirmed H5N1 cases officially
reported to WHO from Dec 2003 to 30 Apr 2006 is
published by WHO. (This information is presented
in: World Health Organization. Epidemiology of
WHO-confirmed human cases of avian influenza A
(H5N1) infection.Weekly Epidemiological Record,
2006, 81:249�260 [available at: <http://www.who.int/wer/2006/wer8127.pdf>]
21 Aug 2006 - Indonesia confirms its 59th human
case in an 35-year-old woman from West Java
(Cikelet/Garut Cluster) (onset date 8 Aug 2006).
In this cluster, there was no evidence of human
to human transmission, poultry deaths were
possibly linked with live chickens returning to
village from live animal market, and there were
possible additional human cases that were not confirmed.
14 Sep 2006 -- Indonesia confirms its 64th human
case in a 5-year-old boy from West Java (onset
date 4 Mar 2006) and (through follow up testing)
its 65th human case in a 27-year-old male from
West Sumatra (onset date 28 May 2006) (brother of
15-year-old girl; was possible human to human transmission).
27 Dec 2006 -- Egypt confirms its 16th, 17th, and
18th human cases in an extended family in
Gharbiyah (onset dates 9-15 Dec 2006). The
isolated viruses had a genetic mutation, linked
in laboratory testing to moderately reduced
susceptibility to oseltamivir. WHO does not change treatment recommendations.
9 Feb 2007 -- The 2nd WHO analysis of
epidemiological data on WHO-confirmed human cases
of avian influenza A (H5N1) infection, 25 Nov
2003 � 24 Nov 2006 is published by WHO.
(Information is presented in World Health
Organization. Update: WHO-confirmed human cases
of avian influenza A (H5N1) infection, 25 Nov
2003 � 24 Nov 2006. Weekly Epidemiological
Record, 2007, 82:41�48. [available at
<http://www.who.int/wer/2007/wer8206.pdf>]
26 Mar 2007 -- Egypt confirms its 27th human
case, in a 3-year-old girl from Aswan (onset date
22 Mar 2007). No epidemiological link is evident
among the 3 recent cases from Aswan.
15 Aug 2007 -- A study describing the
epidemiology of 54 human cases of H5N1 infection
in Indonesia is published. Conclusions included
that 76 percent of cases were associated with
poultry contact, and the source of infection was
not identified in 24 percent of cases.
(Information from this study can be found in
Sedyaningsih, E., Isfandari, S., Setiawaty, V.,
Rifati, L., Harun, S., Purba, W., Imari, S.,
Giriputra, S., Blair, P., Putnam, S., Uyeki, T.,
and Soendoro1, T. 2007. Epidemiology of Cases of
H5N1 Virus Infection in Indonesia, July 2005�June
2006. Journal of Infectious Diseases 196:522 -
527 [available at <http://www.journals.uchicago.edu/doi/pdf/10.1086/519692>.)
9 Dec 2007 -- China confirms its 27th human case,
in a 52-year-old man from Jiangsu (onset date 3
Dec 2007), who is the father of the 26th case [confirmed on 4 Dec 2007].
15 Dec 2007 -- Pakistan informs WHO of 8 people
in the North West Frontier Province that have
tested positive for H5N1 in the national
reference laboratory. These are the 1st suspected
human cases ever reported in Pakistan. The
presence of virus was confirmed in samples from
one of these patients, a 25-year-old man from
Peshawar (onset date 21 Nov 2007).
--
Communicated by:
PRO/MBDS
<promed-mbds@promedmail.org>
[The moderator comment from the ProMED-mail viral
disease moderator "Mod.CP" that accompanied a
similar posting on the general ProMED-mail list,
merits reproduction here: "These reports of bird
flu outbreaks within families in China and
Pakistan are further instances of H5N1 virus
infection involving close (blood) relatives. In
neither case was there any sustained onward
transmission of infection. The circumstances were
different, but in both situations the outcome was
consistent with transmission of virus between
genetically related individuals only. In neither
case was there evidence of mutation of the virus
to a form more easily transmissible from human to
human. In the case of the Chinese father and son
incident the source of the initial infection
remains unknown, whereas in the Pakistani family
the outbreak was clearly initiated by contact
with infected poultry. Furthermore close contact
between susceptible individuals was essential for
transmission as revealed by the negative antibody
test results in the case of the non-resident brother. - Mod.CP"
To further support this comment, in section [4]
above, excerpts from the WHO timeline of major
events in H5N1 avian influenza are presented that
deal with the issue of possible human to human
transmission. As can be seen from the above,
human to human transmission has been suspected in
several cases ("could not be ruled out"), but
probable occurrence has actually been very
limited (see excerpts from 18 Mar 2004 (Viet
Nam), 27 Jan 2005 (Thailand), 21 Jul 2005
(Indonesia), 18 May 2006 (Indonesia), 14 Sep 2006
(Indonesia) and as yet unconfirmed 15 Dec 2007 (Pakistan).
According to the most recent data available on
the WHO website, as of 3 Jan 2008 there have been
348 human cases with 206 deaths confirmed to be
due to H5N1 during the period 2003 through 3 Jan
2008. Cases have been confirmed in 14 countries:
Azerbaijan (8 cases, 5 deaths), Cambodia (7
cases, 7 deaths), China (27 cases, 17 deaths),
Djibouti (1 case, 0 deaths), Egypt (43 cases, 19
deaths), Indonesia (116 cases, 94 deaths), Iraq
(3 cases, 2 deaths), Loa PDR (2 cases, 2 deaths),
Myanmar (1 case, 0 deaths), Nigeria (1 case, 1
death), Pakistan (1 case, 1 death), Thailand (25
cases, 17 deaths), Turkey (12 cases, 4 deaths),
and Viet Nam (101 cases, 47 deaths) (see table
containing number of confirmed cases and deaths
by country and year reported to WHO available at:
<http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_01_03/en/index.html>.)
For a map of China with provinces, see
<http://www.lib.utexas.edu/maps/middle_east_and_asia/china_pol01.jpg>.
Jiangsu is in the far eastern part of China
bordering on the Yellow Sea, just north of Shanghai.
For a map of Pakistan with provinces, see
<http://www.lib.utexas.edu/maps/middle_east_and_asia/pakistan_pol_2002.jpg>.
North West Frontier Province borders with Afghanistan.
For interactive HealthMap/ProMED-mail maps of the
area providing links to other ProMED-mail
postings in the surrounding geographic area, see
<http://healthmap.org/promed?v=36.5,103.9,4> for
China, and <http://healthmap.org/promed?v=30,69.4,5> for Pakistan. - Mod.MPP]

See Also