Epidemiology: H5N1, the deadly Avian Flu Virus

H5N1, kills 81.7% of those infected in Indonesia -- may be the World's next Great Pandemic is working its way across populous, vast, troubled, landscape. [from update 38]

http://www.who.int/csr/disease/avian_influenza/country cases_table_2008_02_05/en/index.html
This site allows you to evaluate the progress of H5N1 -- and from this it is clear that human to human has not happened YET! World-wide the death rate is 62.95% -- if infected -- but in Indonesia, it is 81.06%. Why?

2 APRIL 2008

The Ministry of Health of Indonesia has announced three new cases of human H5N1 avian influenza infection. The cases are not linked epidemiologically. The first is a 15-year-old male student from Subang District, West Java Province who developed symptoms on 19 March, was hospitalized on 22 March and died on 26 March .

The second case is an 11-year-old female student from Bekasi City, West Java Province who developed symptoms on 19 March, was hospitalized on 23 March and died on 28 March.

The third case is a 21-month-old female from Bukit Tinggi, West Sumatra Province who developed symptoms on 17 March, and was hospitalized on 22 March. She is presently recovering in hospital.

The source of infection for all three cases is still under investigation.

Of the 132 cases confirmed to date in Indonesia, 107 have been fatal. Still 81.06% fatal

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Image:WHO
http://www.searo.who.int/en/Section10/Section1027/Section2095/Section2366_13425.asp

Cases confirmed: Indonesia

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Statistics here worldwide as of 17 April 2008
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_04_17/en/index.html

Avian influenza -- Indonesia -- Update #38
FROM WHO
5 February 2008

The Ministry of Health of Indonesia has announced two new cases of human H5N1 avian influenza infection. The first is a 29-year-old female from Tangerang City, Banten Province who developed symptoms on 22 January, was hospitalized on 28 January and died on 2 February. Investigations into the source of her infection are ongoing.

The second case is a 38-year-old female from West Jakarta, Jakarta Province who developed symptoms on 24 January 2008, was hospitalized on 26 January and is currently in hospital in a critical condition. Investigations into the source of her infection are ongoing.

Of the 126 cases confirmed to date in Indonesia, 103 have been fatal.

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Avian influenza – situation in Indonesia – update 32

21 January 2008

The Ministry of Health of Indonesia has announced a new case of human infection of H5N1 avian influenza. An 8-year-old male from Tangerang District, Banten Province developed symptoms on 7 January 2008, was hospitalized on 16 January and died in an AI referral hospital on 18 January. Investigations into the source of his infection are ongoing, however initial reports indicate the case lived in close proximity to a chicken slaughter house.

Of the 119 cases confirmed to date in Indonesia, 97 have been fatal. (81.5%)

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18 December 2007

The Ministry of Health of Indonesia announced the death of a previously confirmed case of H5N1. A 47-year-old man from Tangerang District, Banten Province, expired on December 13, 2007.

A total of 115 cases have been confirmed to date in Indonesia, and 93 (80.8%) have resulted in death.

UPDATE: 15 December 2007

Avian influenza, H5N1 in Pakistan.

Pakistan Ministry of Health informed WHO of 8 suspected human cases of H5N1(Avian Infuenza) infection in the area of Peshawar. These cases followed a series of bird "culling" operations as a result of outbreaks of H5N1 in poultry. One of the suspected cases has recovered and two suspected cases have since perished.

Samples taken from those 8 suspected cases tested positive for H5N1in the Pakistan National Laboratory and were forwarded to a WHO H5N1 Laboratory for confirmation and further analysis. Pakistan Ministry of Health is taking steps to investigate and contain outbreak, including isolating the cases and tracing and monitoring contacts of those infected. A detailed series of epidemiological investigations, providing oseltamivir for individual case management and as prophylaxis is on-going. A thourough review of hospital infection control measures, including enhanced health care-based and community-based surveillance is occurring for any and all acute respiratory infections observed and noted.

WHO provides continuing technical support for the Pakistan Ministry of Health in epidemiological investigations, including reviewing the surveillance, as well as prevention and control measures that are implemented for safely carrying out the viral sequencing of both avian and infected human isolates.

Several poultry outbreaks of H5N1 influenza have occurred in Pakistan since 2006. In 2007, there were detected outbreaks in wild birds. Most of the outbreaks have been in the ‘poultry belt’ of North-West Frontier Province, in the Abbottabad and Mansehra area and cases of infections in wild birds have been found and identified as H5N1 in the Capitol Territory of Islamabad.

UPDATE: 8 October 2007
Indonesia.
WHO reports that a 44-year-old woman from Pekanbaru City in the Riau Province developed Avian Flu symptoms on 1 October and died on 6 October, 2007.

UPDATE: 23 August 2007

The Ministry of Health of Indonesia has announced a new case of human infection of H5N1 avian influenza. A 28-year-old female from Tabanan District, in Bali Province developed symptoms on 14 August, was hospitalized on 18 August and died in hospital on 21 August. The case was a poultry trader. The case investigation found that she collected poultry from villages where outbreaks of avian influenza in poultry had occurred and were later confirmed by rapid testing.

Of the 105 cases confirmed to date in Indonesia, 84 have been fatal. 84/105 = 80% FATALITIES. Since 1Jan2007 86% fatal. Is the virus mutating, and honing itself in Indonesia?

Medical Pictures from CDC From 108,000X Transmission Electron Micrograph, TEM, University of Iowa, artificially colorized. On right, two rods, the virus, and some other organism attaching tendrils to the virus. http://www.lib.uiowa.edu/hardin/md/cdc/8038.html

In the 5 January 2007 issue Science, Vol. 315. no. 5808, p. 32, Dennis Normile in his Article: Human Cases Create Challenges and Puzzles, writes about some of the real baffling difficulties in understanding the spread of Avian Influenza, H5N1, across Indonesia. In this deadly puzzle, everything about the virus and the deaths of both birds and humans becomes a clue. Everything that involves the virus is a possible hint at how to limit the devastation of global population when and if the mutations in the virus allow it to jump from birds to humans, and then human to human quickly and efficiently.

Suppose your dogs, your pets, your loving animal partners in life, are almost out of dog food, and you want to get them food and a doggy treat. So on your way home, you stop by the store and look for their favorite food, buy it, and swing by the butcher counter and see what your behind-the-counter friend, "Cutter", has for the dogs and take it home for them. You feed them, and your younger brother helps you feed them, and in less than two weeks, both you and he are dead. The dogs are fine. Your relatives will care for them, perhaps.

But what if it were chicken, and were not the USA?

The above scenario happened a little differently in Indonesia, because it involved chicken!

It was mid-September, 2006, and a 23-year old Indonesian man on his way home in the the central Java town of Bandung, stopped and bought four freshly dead chickens at a real bargain discount from the poultry market, and carried them home in a universally ubiquitous plastic bag. He and his 20-year old brother butchered the chickens and fed the dogs. Both men are dead by October 1, 2006, and the tissue sample from the younger brother was confirmed as the 68th H5N1 case in humans in Indonesia and its 52nd fatality. The older brother was buried before a tissue sample could be collected. (There was no word on the fate of the dogs, but likely the family is caring for them. Bird flu will not hurt the dogs; unless it mutates.)

It is not clear from the Dennis Normile article whether the older brother was counted as an H5N1 casualty or not -- but we can read between those lines, can't we? It is highly likely the older brother succumbed to the same cause.

NOTE: (If you were the medical statistician keeping the Doomsday Book in your county or province, would you count the older brother as a Bird Flu H5N1 Virus death? Knowing how you would count this statistic would clearly outline your potential as a scientific researcher or a coroner's, or health department's, statistician.)

Indonesia, according to Normile's article, has the greatest number of human deaths from the H5N1 virus -- 57 as of December 17, 2006, but also with that figure comes the highest infection-to-fatality rate so far recorded. Is it because of the virus subtly changing and mutating or is it a genetic manifestation of Indonesians? Indonesia has a death rate of 75%, compared to roughly 67% for China and Thailand, and 45% for Vietnam.

Of course there is no major alarm --yet, but epidemiologists would like to understand just what has happened to the H5N1 virus in Indonesia and to discover the possible blood-line genetic differences in the fatalities. Director General of Indonesia's National Institute of Health Research and Development in Jakarta, Triono Soendoro stated researchers are examining hospital records all over Indonesia for possible older bird flu cases. Also planned are screening tests for poultry farmers and chicken cullers for antibodies which would indicate prior exposure to the deadly virus.
There must be a genetic clue in the mystery of why 1/3 of the cases in humans are bloodline relatives -- whereas marriage relatives had the same exposure but did not become infected. But it is a "clue" only at this stage of understanding. The possible fact of a susceptibility to H5N1 viral infection carried within certain genetic lines may explain the high fatality ratio in Indonesia.

There is a great deal of difficulty involved in dealing with the vast spread of Indonesia's 3000 islands, 220 million people, and 350 ethnic groupings and sub-groupings. It is a challenge to effectively control the spread of the virus in birds like chickens, where they become exposed through airborne exposure to migrating birds, carriers, passing through the nation. Farmers are encouraged to keep their poultry in effective coops and wired cages, inside at night, and isolated from contact with migratory species as well as the neighbor's chickens.

There is also distrust of the Government and justifyably so in many locales. Imagine, in your neighborhood, and with a different disease, say an "imaginary" airborne manifestation of virulent "canine" rabies . . . suppose a U. S Government Health Service employee arrives at your door (with armed assistant) and asks for "Fido"; doesn't handle "Fido" for fear of being bitten, but looks "Fido" over, and then calls to the white Animal Control vehicle parked out front for two environmentally plastic moonsuited specialists with rope poles to take "Fido" for "disposal", sign here please, so we can send you your dog-compensation. Thank you! How would you feel?

It is often that kind of Indonesian treatment for the local farmers who have, rightfully, no reason to suspect their chickens are or have been exposed. And Compensation? It would take 90 days or more here in the US to get aid or compensation for such a program if the tracks of Katrina are recognized. The government comes and destroys all your dinners and suppers for the foreseeable future and says the check will arrive in the mail. Or is brought to you cash by special non-corruptible government courier, next week . . .or two. There are resistances and obstacles.

World Health Organization virologist Keiji Fukuda states that reducing infections in poultry is a critical aspect of reducing the risk to people. But Peter Roeder, an FAO animal health officer points out the obvious fact that there is still no systematic control program.

If you travel, see this link for up to date information on countries with confirmed cases, this is a link to many resources worldwide.

http://www.oie.int/downld/AVIAN%20INFLUENZA/A_AI-Asia.htm

In the US, we have plans. But if the leap by the virus is made to allow H5N1 to be transmitted human to human, we might see if the plans we have laid actually do the trick. If not this virus, it will be some other virus at some other time.

Pay attention to news of the virus's spread, make preparations at home in as much as you can. You might survive this or another pandemic if it shows up and you are ready for it. You may only get a few days warning. Use this link to check your State's planning.

http://www.pandemicflu.gov/whereyoulive/index.html

http://www.pandemicflu.gov/

See a Bird Flu "protective moon suit" here http://www2.dupont.com/Personal_Protection/en_US/assets/downloads/tychem/K-14208AvianFlu.pdf

WHO (http://www.who.org)
CDC (http://www.cdc.gov)
OSHA (http://www.osha.gov)
and FAO (http://www.fao.gov)

CAIRO, Feb 24 (Reuters) -" A five-year-old Egyptian boy who tested positive for bird flu has recovered, the official Middle East News Agency (MENA) reported on Saturday.

Mohamed Ahmed Suleiman recovered after treatment with frontline antiviral Tamiflu and was allowed to go home, MENA quoted Yusri Ragab, director of the Cairo hospital where the child was treated as saying.

Suleiman was the 22nd case to test positive for the H5N1 virus in Egypt, which has the largest bird flu cluster outside Asia. Of the 22 cases, 13 have died.

Most people infected in Egypt had been in contact with live birds kept at home. Bird flu initially caused panic across the country and did extensive damage to the poultry industry, although the sector has largely recovered.

World Health Organisation officials have said a delay in reporting symptoms in Egypt, where many people keep poultry at home, made the virus harder to fight."
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It is not just a tiff between companies and Jakarta Indonesia;
it may become a real matter of life and death, for a significant part of the nation of Indonesia.

http://www.bangkokpost.com/News/22Mar2007_news17.php

March 21, 2007
APIRADEE TREERUTKUARKUL Reports:

Virus samples may be withheld from WHO

Thailand has backed Indonesia in refusing to share samples of the H5N1 avian influenza virus with the World Health Organisation (WHO), unless it can be sure of getting a share of any vaccines made. ''We don't want to take advantage of anyone. Fair distribution is all we want,'' said Public Health Minister Mongkol na Songkhla.

Thailand will make its case at a WHO-organised meeting on vaccine agreements in Jakarta next week.

Deputy Health Minister Morakot Kornkasem and special adviser to the health minister Suwit Wibulpolprasert will represent Thailand in talks about sharing virus samples.

Dr Mongkol said he believed the 10 Association of Southeast Asian Nations country members would take the same stance as they were facing similar problems in dealing with bird flu outbreaks.

The WHO has called a meeting to seek ways of making sure drug companies can make more vaccines, and that these vaccines will be available to all countries that need them.

Indonesia insisted that it would only share samples of the H5N1 virus strain if it could be certain that the samples would not be used to make vaccines that would profit any company or another country. It feared that it might be the last to get vaccines against H5N1 should the disease evolve into a pandemic.

Dr Mongkol claimed the country had not received any benefits by sharing virus samples with vaccine companies via the WHO. It seemed that companies received most benefits from developing vaccines, before offering small benefits to cash-strapped countries for ''charitable purposes''.

Dr Suwit said the virus sharing policy should be based on ''fair benefit distribution'' and that the WHO as the organisation overseeing the issue on behalf of its member nations should develop a system to ensure that developing countries most at risk of an influenza pandemic would get the vaccines.

At present, the country would continue sending samples of the virus to WHO if any new human case was found, he said.

P. T. Jayawickramarajah, the WHO representative in Thailand, said the WHO's stance was neutral.

Meanwhile, Burma has now found bird flu in its poultry, according to Burmese state media. More than 1,645 chickens had died of the virus and 20,000 chickens in a Rangoon suburb were killed. No human cases had yet been reported.