H5N1, Bird Flu Updates

indigo girl · Aug 11, 2011

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19941

AVIAN INFLUENZA A(H5N1) IN HUMANS: NEW INSIGHTS FROM A LINE LIST OF WORLD HEALTH ORGANIZATION CONFIRMED CASES, SEPTEMBER 2006 TO AUGUST 2010
The threat of avian influenza (AI) viruses to humans in Europe in 2005 prompted the Robert Koch Institute to establish a routine monitoring instrument condensing information on all human AI cases worldwide reported from the World Health Organization (WHO) and other sources into a line list for further analysis. The 235 confirmed AI cases captured from September 2006 to August 2010 had a case fatality rate of 56% (132/235), ranging from 28% (27/98) in Egypt to 87% (71/82) in Indonesia. In a multivariable analysis, odds of dying increased by 33% with each day that passed from symptom onset until hospitalisation (OR: 1.33, p=0.002). In relation to children of 0-9 years, odds of fatal outcome were more than six times higher in 10-19 year-olds and 20-29 year-olds (OR: 6.06, 95% CI: 1.89-19.48, p=0.002 and OR: 6.16, 95% CI: 2.05-18.53, p=0.001, respectively), and nearly five times higher in patients of 30 years and older (OR: 4.71, 95% CI: 1.56-14.27, p=0.006) irrespective of the country, which had notified WHO of the cases. The situation in Egypt was special in that case number and incidence in children were more than twice as high as in any other age group or country. With this study, we show that data from the public domain yield important epidemiological information on the global AI situation. This approach to establish a line list is time-consuming but a line list is a prerequisite to such evaluations. We thus would like to encourage the placing of a publicly accessible line list of anonymised human AI cases, e.g. directly by WHO. This might enhance our understanding of AI in humans and permit the rapid detection of changes in its epidemiology with implications for human health.

(hat tip avian flu diary)

Laidback Al · Aug 13, 2011

H5N1 CFR for the period between December, 2003 and August, 2006

The case fatality rate for human H5N1 cases is high. The Eurosurveillance study only looked at 234 confirmed cases between September of 2006 and August, 2010 and discovered a CFR of 56%. However, there were actually 245 other human H5N1 cases confirmed by WHO between 2003 and August of 2006 that were not included in the study. Of these earlier infected individuals, 143 died leading to a CFR of 58% for the earlier period. The 2% drop in the case fatality rate between these two datasets is insignificant. What is significant is that about 6 out of 10 people who become infected with H5N1 do not survive.

indigo girl · Aug 13, 2011

H5N1 CFR for the period between December, 2003 and August, 2006
The case fatality rate for human H5N1 cases is high. The Eurosurveillance study only looked at 234 confirmed cases between September of 2006 and August, 2010 and discovered a CFR of 56%. However, there were actually 245 other human H5N1 cases confirmed by WHO between 2003 and August of 2006 that were not included in the study. Of these earlier infected individuals, 143 died leading to a CFR of 58% for the earlier period. The 2% drop in the case fatality rate between these two datasets is insignificant. What is significant is that about 6 out of 10 people who become infected with H5N1 do not survive.

Yes, but why is that? Here is the CIDRAP analysis of that study.

http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/aug1211h5n1-jw.html

Analysis of H5N1 cases finds sinking fatality rate
...57% of patients were women...
Children under age 10 were far less likely to die of the illness than were older children and adults, the analysis shows. Compared with the under-10 group, patients aged 10 to 19 and 20 to 29 were more than six times as likely to succumb. Adults aged 30 and up had almost a fivefold increase in risk, compared with children under 10.
...in Egypt, H5N1 survivors averaged just 4 years old, versus 25 years for patients who died--a much larger difference than in the other countries. Also, the CFR in Egypt was significantly higher for females than males: 39% versus 12%.
...the low overall CFR in Egypt can't be explained entirely by sex-related differences in CFR and the high proportion of children among Egyptian cases. They say that after adjustment for differences in these factors and in time to hospitalization, Egyptians still had the lowest risk of dying. This might reflect different H5N1 clades circulating in Egypt and in Asia and various other factors, they suggest.
...the researchers recommend that an organization such as the WHO establish and continuously update a case-based database for avian flu in humans. "Open access to analysable data might accelerate the identification and implementation of research questions and surveillance priorities and thus enhance our understanding of--still mostly fatal--AI in humans," they write.

Laidback Al · Aug 13, 2011

Pandemic CFR

In response to post #242 and the CIDRAP summary . . .

The most devastating pandemic in modern times was the 1918 pandemic. The estimated CFR for that pandemic was only 2-2.5%. Based on all confirmed WHO H5N1 cases through today, the CFR stand at 58% (330/564) for H5N1. World societies today could probably not handle a pandemic with even a 2% CFR. My point is that a pandemic in this modern age with a CFR of 20 or 10 or even 5 times the rate in 1918 would have unimaginable consequences. Scientists can quibble over whether the CFR for H5N1 is 56% or 58% and is stable, increasing, or even decreasing. But the reality is that the CFR for a future pandemic will need to be below 2% if civilization, as we know it, is to survive.

I do think there is hope. The Egyptian data hint at how a lower CFR could evolve for this novel influenza virus. From the Eurosurveillance study itself "Regarding the decreasing CFR in Egypt, Schroedl [32] suggested that the circulating AI virus strain may have become less virulent and more apt to spreading among children."

As we know children are highly susceptible to influenza, yet here in Egypt we have young children actually recovering and surviving at a greater rate than adults. And these kids are surviving infection from a novel virus in which they have no protective immunity. Generally, as was shown in the most recent H1N1 pandemic, adults have cross-protective immunity from novel influenza strains because of a lifetime of exposure to influenza. Children do not have the benefit of exposure to lots of strains of influenza, yet children in Egypt are surviving a novel H5N1 infection more frequently than adults. The circumstances of why this is occurring is unclear, but deserve future research.

indigo girl · Aug 20, 2011

Cambodia

http://www.who.int/csr/don/2011_08_19/en/index.html

Seven days from symptom onset to death, and only 6 years old...

The case was a 6 year old female from Taing Thleung Village, Mepring Commune, Cheung Prey District, Kampong Cham Province.
She developed symptoms on 7 August, was initially treated by local practitioners with no effect and was later admitted to Kantha Bopha Children Hospital in Phnom Penh on 12 August. She died on 14 August, two days after admission.
There have been reports of poultry die off in her village and the case is reported to have had exposure to sick poultry. The female is the eighteenth person in Cambodia to become infected with the H5N1 virus and the sixteenth to die from complications of the disease. All eight cases of H5N1 infections in humans in Cambodia this year have been fatal.

indigo girl · Aug 30, 2011

FAO warns of possible H5N1 resurgence in birds

http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/aug2911h5n1.html

... a new H5N1 variant in Vietnam and China, called clade 2.3.2.1, is able to sidestep existing poultry vaccines. The strain has invaded most of northern and central Vietnam, and the country suspended its spring vaccination campaign this year as a result, the FAO said.
"Viet Nam's veterinary services are on high alert and reportedly considering a novel, targeted vaccination campaign this fall," the FAO stated. "Virus circulation in Viet Nam poses a direct threat to Cambodia, Thailand and Malaysia as well as endangering the Korean peninsula and Japan further afield. Wild bird migration can also spread the virus to other continents."
Lubroth said the recent increase in outbreaks could mean there will be a "flare-up" of H5N1 this fall in winter, with the virus popping up in unexpected places. The countries where the virus is endemic--Bangladesh, China, Egypt, India, Indonesia and Vietnam--are likely to face the biggest problems, but no country can consider itself safe, he said.

indigo girl · Aug 30, 2011

http://www.scottmcpherson.net/journal/2011/8/29/fao-warns-of-spread-of-fujian-h5n1-mutation.html

As of August 19th of this year, there were more confirmedhuman bird flu cases than in all of 2004, 2008 or 2010. Keep in mind that this includes an alarming increase in Egyptian human cases and accompanying deaths. But most distressing is the sudden re-emergence of Cambodia as a bird flu incubator. While Egypt has had 32 cases and 12 deaths to date, Cambodia has had 8 cases -- all fatal. Of course, we shrug our shoulders at Indonesia, which continues to befuddle Western experts with its distressing lack of transparency.
So 2011 already ranks as the fifth-worst year for human H5N1, and we have the beginnings of flu season in which to add to that total. It would take a huge, but not impossible, acceleration of human cases to move it past 2009's 73 totals. that is the good news. But the FAO apparently sees a cause-and-effect relationship between the initial discovery of a new clade, the distribution of that new clade, its ability to overtake the existing clade as the dominant substrain, and then extend its reach back into humanity. Now it is hard to calculate an accurate Case Fatality Rate (CFR) based on such low numbers, but it is safe to say that of all the documented H5N1 human cases, we are still at a reliable 50% figure, meaning that half of all human bird flu patients either die of the disease or its byproducts. In Egypt, that figure is currently 37%; in Cambodia and Indonesia, it is much, much higher.
The FAO is signaling that it fully expects bird flu cases in poultry and in humans to accelerate in 2011. The efforts to vaccinate poultry, while admirable, have failed to eradicate the disease (did we ever really expect this effort to be successful?). Pockets of H5N1 remained and pockets remain today. While migratory wildfowl (laden with virus) are the primary culprit, humans and their myriad and almost universally bad ways of moving poultry from area to area are also culpable. Perhaps even more so, when humans smuggle sick and dying poultry across borders, as happens hourly from the Bird Flu Ho Chi Minh Trail from Vietnam into China.

indigo girl · Sep 5, 2011

The Smart Science of "Contagion"

Dr. Ian Lipkin, balanced a consultative role on the movie with his responsibilities as director of the Center for Infection and Immunity at Columbia and co-chair of the National Biosurveillance Advisory Subcommittee.

http://www.salon.com/entertainment/movies/contagion/index.html?story=/ent/movies/feature/2011/09/03/lipkin_contagion&source=newsletter&utm_source=contactology&utm_medium=email&utm_campaign=Salon_Daily%2520Newsletter%2520%2528Not%2520Premium%2529_7_30_110

The movie is based on the cold, hard facts:

We don't have crystal balls that allow us to tell you whether a virus is going to be pandemic, with high pathogenicity, or not. We do know the following: We know that we dodged a bullet on SARS, because SARS actually came through the United States, but it didn't get established here. We know that thousands of people died in China -- and I was in China; I saw the havoc it wreaked there. It was profound. And we know that if we were to have some sort of an outbreak -- or pandemic, worse yet -- in the United States, we don't at present have the tools that are required to rapidly ramp up some sort of a strategy for making vaccines and distributing them. Those are just the cold, hard facts.
We make influenza vaccines in chicken eggs right now, right? Which means we need, what, 300 million eggs, fertile eggs in order to make vaccines? That's insane! We have to change the way we do these things. Furthermore, much of the vaccine manufacturing has moved out of the United States, so when we needed lots of vaccine in 2009, there were people who ran out and couldn't make it for us. Do you remember that? We had contaminations of various facilities. That was a situation where that particular virus was not a major threat to humankind. But the next one may be.
The problem, of course, is that, if this happens two or three years in a row -- it happens with SARS, and it happens with H1N1, and it happens with H5N1 and so forth -- people say, "OK, every time we have a new flu season, you guys tell us the sky is falling, and then the sky doesn't fall." And at some point they also say: "All right, we're done with this hype." My argument is that if we actually make generic improvements to all these different platforms -- recognition of risk, response to risk -- then whatever it is, whether it's tuberculosis or SARS or flu or whatever, we'll be in a better position to deal with it.

Laidback Al · Oct 10, 2011

New H5N1 Human Cases in Indonesia

Yesterday, the Indonesia Ministry of Health announced the case of a young child from West Jakarta who died on August 25, 2011. This is the first case confirmed in Indonesia by the Ministry of Health since June 2011. (link)

And two young brothers from Bali were locally confirmed with H5N1 today. These two cases have not yet been verified by the Ministry of Health. (link)

Presumably these cases will be confirmed by WHO shortly.

Laidback Al · Oct 17, 2011

Bird Flu is heating up in Indonesia -

Status update -

In the past week and a half, a mother, her son, and her daughter have all died from suspected bird flu infection on the island of Bali.

http://www.flutrackers.com/forum/showthread.php?t=174971

Another individual is hospitalized on the island of Bali with bird flu symptoms.

http://www.flutrackers.com/forum/showthread.php?t=174992

And 5 individuals are hospitalized and receiving treatment for H5N1 on the island of Lombok.

http://www.flutrackers.com/forum/showthread.php?t=174951

indigo girl · Oct 30, 2011

WHO: Indonesian Bird Flu Update #7

http://afludiary.blogspot.com/2011/10/who-indonesian-bird-flu-update-7.html

The World Health Organization has posted an update on the two Indonesian children who died from the H5N1 virus earlier in the month (see Bird Flu Claims Two Lives On Bali).
Complicating this story, the mother of these two children died about a week later. But from media reports it isn't clear whether appropriate samples were taken for lab testing before she was buried (see Indonesia: Bali Bird Flu Suspect Dies, Suspect Cases Increase in Mataram).
For now, she remains an unconfirmed case.

Laidback Al · Nov 4, 2011

WHO: Egypt H5N1 Update

Yesterday, WHO announced the 569th officially confirmed case of H5N1. The 1 year old boy from Gharbia Governorate, Egypt, was symptomatic on September 17, 2011. He was hospitalized on September 21, treated with oseltamivir, recovered, and was released on September 25, 2011.

http://www.who.int/csr/don/2011_11_02/en/index.html

Although Egypt has reported 33 human cases of H5N1 in 2011, the good news is that a majority of them (21) have survived.

http://www.who.int/influenza/human_animal_interface/EN_GIP_20111102CumulativeNumberH5N1casesN.pdf