Penumbra Pandemia

Comments section of the Effect Measure blog post
Message to WHO: there is no barn door to close by GaudiaRay:
"This afternoon, Niman posted a Commentary a quote from Nature Magazine article to appear tomorrow:
> What caused the suspected human-to-human transmission at Kubu Sembelang is still a mystery. Nature has learned that the cases differed from past Indonesia cases, in that they had much higher viral loads in the throat and nose. Human-to-human transmission is more likely through droplets coughed from the nose and throat than from infections further down the respiratory tract.
---
GaudiaRay | Email | Homepage | 05.31.06 - 8:54 pm | #"

Comments section of the Effect Measure blog post
Message to WHO: there is no barn door to close by Revere:
"I suspect H5N1 will offer some variations on the H2H theme. H5N1 has already generated some fairly large clusters in Turkey, Azerbaijan, and Indonesia. Each was an incremental increase over most of the two dozen H2H clusters and these large clusters and long chains were contained.
The role of Tamiflu in the containment is unclear. All but one of the confirmed north Sumatra cluster cases died, but as of now there are no reported new cases, even though unprotected family members tend to the sole survivor.
These data suggest H2H currently has a small window of opportunity to spread. Turkey's change was almost certainly due to S227N. Even though the 9 Azerebaijan cases were just published, there is no mention of genetic chnage. The author;s focus on wild bird feathers, while simply stating that H2H cannot be excluded, which is typical of the WHO response, which is to minimiae the H2H compenent, even when it is glaringly obvious.
These big red flags H5N1 keeps waving have had limited spread, and an H5N1 which spreads like SARS is possible. SARS came VERY close to breaking out into a much bigger problem, but its long incibation period allowed for quarantine efforts to have some effect.
A fully transmissible H5N1 will happen sooner or later, but its evolution to that level may take a few baby steps first, and containment effects may be effective initially.
However, the baby steps will still be a major shock tp the general public, because the public doesn't ubnderstand how many H2H clusters there have been already, and doesn't appreciate the incremental changes that have already happened.
PB2 E627K is fixed in the Qinghai starin, and HA S227N may be more common than advertised. NAMRU-3 was involved with Azerbaijan, but no sequences have been released, although the paper did acknowledge that the H5N1 in Azerbaijan was the Qinghai strain and close to isoaltes from Italy
WHO is still playing fast and loose with sequences, and the public should demand the release.
Henry Niman | Email | Homepage | 05.31.06 - 7:45 am | #"

"Viitasaari esillä EU:n pandemialääkevaraston paikaksi
27.05.2006 10.28
Sosiaali- ja terveysministeriön alainen lääkelaitos selvittää pikaisesti, soveltuisiko Viitasaari EU:n keskeisen pandemialääkevaraston sijaintipaikaksi. Koko EU:ta palveleva varasto sijoitettaisiin Viitasaaren Hakovuoreen louhittuun luolastoon, Keskisuomalainen kertoi lauantaina. Luolastossa on tällä hetkellä runsaasti tyhjillään olevaa tilaa.
Peruspalveluministeri Liisa Hyssälä pitää selvityksen tekemistä tarpeellisena. Hän aikoo ottaa lääkevaraston sijoittamisen esille EU:n terveysministerineuvoston kokouksessa Luxemburgissa ensi viikolla.
Strategisen lääkevaraston perustaminen ja sijoittaminen on kokouksen tärkein aihe. Vielä ei tiedetä, aiotaanko lääkevarasto perustaa jo ensi viikon kokouksessa."

"UNDIAGNOSED DIE-OFF, WILD BIRDS - FINLAND (JURMO)(02)
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Tue, 30 May 2006
From: Marja Laeslehto ---
The Evira [Finnish Food Safety Authority] Research Department has
investigated samples from dead wild birds found on the island of
Jurmo in the Finnish Archipelago. No H5N1 virus was detected.
--
Marja Laeslehto
Finnish Food Safety Authority Evira/Communications Unit
Helsinki, Finland
---"
Still wondering what was detected.

"---
Employers should draft plans now, before outbreak, disruptions hit home
By Tracy Wheeler
Beacon Journal medical writer
What if 40 percent of your employees couldn't show up for work tomorrow?
If your company's answer is, ``We haven't really thought about it,'' expect to be broadsided by major business disruptions if an influenza pandemic ever comes to be.
And expect that disruption to spread throughout the community, hurting customers, vendors, suppliers and your employees.
`It's better to be thinking about it and get the question out on the table now,' said Summit County Health Commissioner Gene Nixon, `rather than wait to act until we're in the middle of a crisis.'
---
Pandemic flu is very different from other emergency incidents businesses may face, such as natural disasters or power outages, which are often short-lived problems. Pandemic flu could last 12 to 18 months, as the disease circles the globe in two or three waves.
Preparing for outbreak
The U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) have developed a checklist for businesses, which can be found at www.pandemicflu.gov/plan/tab4.html. Among the suggestions:
- Identify your company's No. 1 priority and focus your resources on it. Identify key personnel and cross-train employees to do jobs that are out of their area of expertise. Reach out to retirees, freelancers or contract workers before the crisis hits.
- Establish a liberal sick-leave policy unique to a pandemic. This policy would include guidelines on when a sick worker is no longer infectious and can return to work. The policy should also allow employees to miss work due to personal or family illness, community quarantines, school closures and public transportation shutdowns.
This could be one of the most crucial aspects in pandemic planning, Nixon said. If workers aren't paid for sick time, there's an incentive to show up sick at work.
---
- Create guidelines to limit face-to-face contact (including hand shaking, seating in meetings and shared workstations) among employees, as well as between employees and customers. Encourage telecommuting and flexible work hours when possible.
---
- Keep in contact with federal, state and local public health agencies and emergency responders to participate in their planning processes, share your pandemic plans and understand their capabilities and plans.
---
The Summit County Health Department will soon have a worker dedicated full time to helping businesses, schools and local governments plan for the pandemic. ---"

"Extended Human-To-Human H5N1 Transmission Review
By Dr. Henry L. Niman, PhD
24.5.2006
Recombinomics.com
--- the current cluster in Indonesia may not be the longest chain, but it is the deadliest, with seven fatal cases in the eight member cluster. This may be due to a combination of a cleavage site common in Asian H5n1 isolates, coupled with a PB2 E627K polymorphism that is usually not found in birds and is almost always fatal when coupled with the H5N1 cleavage site."

'Nancy' in the Comments section of the Effect Measure blog post Nice place for a virus:
"Revere: There is a passage in the article quoting Nidom as follows, "I am convinced human-to-human infection has been taking place because studies have found the development of H3N2 and H1N1 strains of bird flu virus which originated from H5N1 virus."
Can you explain what this means, please? What are the implications? From the context of the article, he makes it sound as if it's no big deal. To those of us who are epidemiolgists, it sounds like H5N1 has been doing the all-dreaded "mixing" with human flu viruses.
Nancy | Email | Homepage | 05.27.06 - 9:27 am"

"Extended Human to Human H5N1 Transmission Review
Recombinomics Commentary
May 24, 2006

--- Earlier this year there were two large clusters involving several families. The first began at the end of 2005 and extended well into January. This cluster was in Turkey and confirmed cases were identified in three families of cousins. However, the WHO updates failed to indicate that the three family members were related and failed to mention the hospitalizations of family members when other family members were confirmed. Media reports suggest the index case infected his three siblings. The index case and two siblings died and were H5N1 confirmed. Cousins were at a family gathering, and they also developed symptoms and 10 family members were hospitalized. Two were placed in intensive care and tested positive for H5N1. The timing of the cases suggested that these two families represented H2H2H2H. However, these cases were followed by the hospitalization of two more cousins who also tested positive and one died. Thus the chain would then be extended to H2H2H2H2H. However, there hospitalization was followed by the hospitalization of yet another set (five) of cousins who were said to have tested negative.
The reports from Turkey stopped suddenly when the members of the fourth family were hospitalized and the number of negative cases, including the fourth sibling of the index case, raised credibility issues. However, WHO announced in January that they were planning on collecting 10,000 serum samples from contacts of the cases to determine the level of H5N1 transmission. Most patients infected with H5N1 will develop peak serum antibodies about 3 weeks after infections. Thus, samples should have been collected in late January and February. The results from that testing has not been disclosed.
Since the cases had connections with poultry. These cases were not considered as H2H (or H2H2H2H2H), but there is little reason for the cases to be focus in these three related families. In Azerbaijan, cases extended over a month, and although wild bird feathers may have led to infection of the index case, it is likely than transmission to family members over such an extended time period was a long H2H chain.
Thus, the current cluster in Indonesia may not be the longest chain, but it is the deadliest, with seven fatal cases in the eight member cluster. This may be due to a combination of a cleavage site common in Asian H5n1 isolates, coupled with a PB2 E627K polymorphism that is usually not found in birds and is almost always fatal when coupled with the H5N1 cleavage site."

"World Health Group to Leave Bird Flu Alert Unchanged (Update2)
--- Genetic sequencing is incomplete for samples of the H5N1 virus strain from the seven Indonesians, Cheng said. The dollar rose against the yen after the WHO said the people may have caught the disease from humans, not animals. Cases involving sustained human transmission would suggest the virus has undergone genetic changes making it more infectious.
The U.S. currency's rise in overnight trading reflected concerns about emerging market investments. The Indonesian rupiah, Thai baht and Singapore dollar also fell in overnight trading against the dollar.

`Safe Haven'
``You're seeing the dollar as a safe haven,'' said Brian Taylor, chief currency trader at Manufacturers & Traders Trust in Buffalo, New York. The WHO's finding yesterday is still affecting current markets, he said. ``Anything such as that, the dollar gets a bid.''
A pandemic such as the one that killed 50 million people in 1918 may take more than 142 million lives and cause the world's economy to shrink by an eighth, according to a report in February by the Lowy Institute and Australian National University.
At least 124 of 218 people known to have been infected with the H5N1 virus have died, the WHO said yesterday. Almost all of the cases confirmed by the WHO since late 2003 can be traced to direct contact with sick or dead birds.
Disease trackers found strong evidence in 2004 of direct human-to-human transmission of H5N1 in Thailand. In that case, the H5N1 virus probably spread from an 11-year-old girl to her aunt and mother, killing the mother and daughter, scientists reported in the Jan. 27, 2005, issue of the New England Journal of Medicine. People who had casual contact with the girl weren't infected.
---
On the WHO's six-level pandemic alert system, level three means ``no or very limited human-to-human transmission.'' To raise the alert to the next level, the agency would have to see ``evidence of increased human-to-human transmission,'' or signs that the virus has gained the ability to spread through more casual contact."

Revere at 7:55 am Wednesday May 24, 2006
Effect Measure Blog:
"Indonesia: probably H2H2H
WHO is now saying what could be inferred from their update yesterday: it is likely that for the first time H5N1 has spread from human to human to human -- three generations of cases, possibly four. This does not mean that a pandemic strain has started but it is another warning signal.
If we take the statement that there has been no change in the virus (let's see the sequences!), then there is another inference we might make. This is just the first time WHO has acknowledged this, not the first time it has happened. Since many cases in Vietnam, China and elsewhere lack solid evidence of close contact with poultry this may have happened many times over.
---
As a result of this cogent evidence in Indonesia, WHO may convene a standing committee of experts to decide if the pandemic alert level should move from the current Phase 3 to a new Phase 4.
---
Many (including us) believe we have been in Phase 4 for some time, but WHO has been reluctant to make the call. It appears now they may do so. We shall see. WHO may still decide there is as yet no sufficient evidence the virus has changed and keep the level at 3.
---
"An awful lot of information" is not what we are getting, however. We do get much handwringing about the difficulty of getting cooperation from fearful and suspicious villagers whose relationship with the central government in Indonesia has been distant and hostile.
---
While you're at it send some of those experts on social mobilization (and social responsibility) to Geneva, Atlanta, Weybridge, Hong Kong, Nashville, Los Alamos, New York. It is not just villagers that aren't cooperating. The genetic sequences need to be released, not just from this cluster but from many others WHO, CDC and individual researchers have not deposited in GenBank (discussion at Flu Wiki here). The lack of cooperation from knowledgeable international and national health officials and eminent scientists has been worse than that of the frightened villagers. It is inexcusable and irresponsible.
To my public health colleagues: Get your own house in order before blaming desperate villagers. Release the sequences and write your papers afterwards. These are not ordinary times. Your resumés are long enough."

"G8 health ministers discuss preparations for bird flu conference
22.05.2006, 23.58
GENEVA, May 22 (Itar-Tass) - The health ministers of the G8 countries have discussed preparations for a conference on bird flu to be held in Vienna on June 7 and 8.
Russian Minister of Health and Social Development Mikhail Zurabov told Itar-Tass: “We should fulfil certain tasks. First of all, all countries should meet the financial commitments of the common action plan. The second task is preparations for a possible bird flu pandemic. And finally, it is necessary to verify the list of countries that need assistance from donor countries and a trust fund that is being set up.”
Zurabov said his counterparts from the G8 countries had paid special attention to such issues as “vaccine development and improvement of the transportation system for the biological materials necessary for the identification of the bird flu strain that has caused illness in a certain region.”
“A preliminary agreement was reached that a laboratory for strain identification will be equipped and will start operating at the research center of Virology and Biotechnology Vektor near Novosibirsk,” Zurabov said.
The minister is leading the Russian delegation to the 59th annual session of the World Health Organization that is currently underway in Geneva.

H5N1 Cluster in Medan Indonesia Grows
Recombinomics Commentary
May 22, 2006
"Local tests on Monday confirmed that a sixth family member, a 32 year old man, been infected with bird flu, said Kandun.
"He is the father of one of the victims, " Kandun said.
The above confirmation extends the transmission chain in the H5N1 bird flu cluster hospitalized in Medan, Indonesia. The size of the cluster is again at eight. Six have died and H5N1 has been confirmed in all except the index case, who died prior to collection of samples. The latest positive may have extended the human-to-human transmission (H2H) to H2H2H2H because the 10 year old nephew was the last to develop symptoms suggest that infection represented H2H2H and now confirmation of the infection of the nephew's father would add one more link to the chain.
This would be the longest H5N1 transmission chain reported to date, and raise questions about the sequence of the H5N1. The dominant human sequence in the Jakarta area (ranging from Lampung to West Java, including Tangerang, Jakarta, and Bekasi) has a novel cleavage site RESRRKKR and represents a clade that is distinct from bird H5N1 sequences from Indonesia, although the sequence is closer to Indonesian H5N1 sequences than any other published H5N1 sequences. However,. at least one sequence has a wild type cleavage site, RERRRKKR, and is closely related to the bird sequences, indicating two distinct sequence are co-circulating in the Jakarta area.
If the Medan cluster has the wild type sequence, the number of human sequences that are closely related to the published bird sequences would increase dramatically. The co-circulation of two distinct sequences in Indonesia would be cause for concern, because immunization may require two distinct vaccines and teh two sequences can easily recombine to produce more genetic diversity..
Clearly the H5N1 sequences in the WHO private database should be released immediately, and animal sequences throughout Indonesia should be significantly expanded. Recently there have been several H5N1 positive patients in Jakarta in West Java and Surabaya in East Java in addition to the cluster in North Sumatra.

A Rwandan friend of mine analyzed the epidemics situation in Africa:
"People don't even know what is bird influenza - let alone what is H5N1"
"Maybe the most usual sickness is malaria. It is so common that almost all fever is called malaria - even if it really was something else."
"In Africa people don't have any means to distinguish bird influenza from other deadly fevers. There is no public health care. Everything is private sector i.e. for rich people. In Africa most people are not rich."

Phase 4: Small cluster(s) with limited localized human-to-human transmission
Phase 5: Larger cluster(s) but human-to-human spread still localized.

"May 21, (foodconsumer.org)
Epidemiologists have tested pigs, chickens, ducks and geese for the presence of the virus and had found bird flu antibodies were detected in pigs raised by the family. However nasal swabs taken from the pigs were returned negative. "We can't rule either way (human-to-human or animal-to-human) at this stage, we're still doing investigations," Setiogi said.
She added that the investigators were facing some logistical difficulties since the said family was still in mourning. "We are dealing with a family that has lost so many members and which has suffered such a loss ... they may not remember what happened, they may tell you something wrong," she added. "When you ask again, you get a different answer. So it's not easy for them to think easily and answer questions."
Clusters of human infections are a worrying trend since this means that people staying close together either got infected from a single source (which is highly unlikely) or got it from each other. This is a nightmare scenario for health workers. The Indonesian family cluster is the largest seen until now, but it must be stressed that such clusters occurred in Turkey and Azerbaijan as well.
Dr. Guenael Rodier, special adviser for communicable diseases to the regional director of the WHO's European office said that the occurrence of these clusters should serve as a warning, "Of course you can imagine that some human beings offer more binding opportunity for the virus than others," he said. "It's perfectly legitimate to think about it. But . . . we don't have enough cases today and pathology results to be able to document that. We can always explore a hypothesis. But my experience from the field is that often we have simple answers."
Scientists are also speculating whether genetic susceptibility is involved in such human clusters. Henry Niman, Ph.D., President of Recombinomics is calling on the WHO to release the human H5N1 bird flu sequences from the dead family members. He cited the index case who fell ill on April 27 and died on May 4 as being the key to this puzzle. The case was a 37-year-old woman who was buried without any tests being conducted.
Since her death six other members of her family have including two sons, a brother, a sister, a nephew and a niece have either fallen ill or succumbed to the bird flu virus. It is unlikely that the index case will be confirmed.
---
The CDC says that some of the common symptoms of bird flu are fever, cough, sore throat, and muscle aches, eye infections, pneumonia, and severe respiratory diseases."

"Bird flu confirmed in Omsk Region (Russia)
State Scientific Vector Center of Virology and Biotechnology confirmed outbreak of bird flu in Maximovka village of Tyukalinsky district in Omsk Region (Russia), where 86 hens died recently; State Irtysh TV-Channel is quoted by a REGNUM correspondent as reporting on May 16.
The dead poultry’s blood samples were sent for research to Novosibirsk, where specialists confirmed the worst assumptions on the eve. At present, villagers’ households at Maximovka village are being treated by chemical agents, population is medically examined, and homesteads rounds on poultry’s close confinement recommenced.
Nearly 4,000 hens have been vaccinated for bird flu prophylaxis in Maximovka. No poultry deaths were registered during last 24 h."

Onhan kieltämättä aika mielenkiintoista, että Suomessa sadoista kuolleista Jurmon linnuista ei saatu kunnollisia näytteitä, mutta Venäjän kaukaisen Omskin muutamasta kymmenestä kuolleesta linnusta saadaan...

Effect Measure
20.5.2006:
"There has been much talk about the possibility of domestic cats being infected with H5N1 and some cases have been described (see posts here, here and here). Cats eating infected birds is suspected as the source of infection in some of these cases.
Cats, both feral and domestic, are common inhabitants of urban environments. So are pigeons. We've been told we don't have to worry about pigeons and bird flu. But this paper (which got by me when it appeared in Emerging Infectious Diseases in April) tells a somewhat different story.
'In early February 2004, during the outbreak of HPAI (H5N1) in Thailand, a carcass of a 2-year-old male cat (Felis catus) was taken in an icebox 6 hours postmortem to the Faculty of Veterinary Medicine at Kasetsart University, Nakornpathom, Thailand. The cat's owner volunteered the information that the cat had eaten a pigeon (Columba levia) carcass 5 days before illness onset. The owner reported that the cat had a temperature of 41°C, was panting, and appeared to be depressed. Furthermore, the cat had convulsions and ataxia and died 2 days after onset of illness. The cat was given a single dose of 75 mg aspirin 1 day before it died; however, its body temperature remained elevated. Many dead pigeons were found in the area where the cat lived.'
H5N1 was isolated from the cat and from dead pigeons in the area. The genetic sequences of the viruses matched closely and resembled the sequences of the H5N1 circulating simultaneously in poultry and large zoo cats (tigers, leopards) in early 2004 in southeast Asia. Horizontal transmission ("cat to cat") has been described elsewhere but so far no one has shown any cases of cat to human. In April Dr. Peter Roeder, a Food and Agriculture Organization scientist working with Indonesian colleagues, was reported setting up a study to see if cats were playing a role in the Indonesian outbreak but we don't know if that study is happening or not. The Indonesians have a history of foot dragging. Earlier, the former NAMRU2 epidemiologist Dr. Andrew Jeremijenko had swabbed a kitten in Indonesia and isolated an H5N1 that was a close match for a virus isolated from a human.
It seems not a day goes by that this virus doesn't confront us with something new and unsettling.

"Hengitystieinfektioepidemian aiheuttaja epäselvä Tohmajärvellä
Tohmajärven terveyskeskuksen hengitystieinfektioepidemian aiheuttaja ei ole vielä selvinnyt. Vuodeosastolla sairastui viikonvaiheessa kuumeiseen hengitystietulehdukseen 15 potilasta ja yhdeksän hoitajaa.
Viime yönä kuumeisia sairastapauksia tuli lisää kolme, mutta vielä ei tiedetä, onko kyseessä sama hengitystietulehdus. Johtava lääkäri Markku Savola kertoo, että taudinaiheuttajasta saadaan mahdollisesti jotakin tietoa huomenna. Tarkemmat tiedot jäävät ensi viikkoon.
Taudin aiheuttanutta bakteeria- tai virusta selvitetään verinäytteistä. Myös terveyskeskuksen vesijohtovesi ja ilmastointi tutkitaan.
Vuodeosastolla on työntekijöitä kaikkiaan 27. Osastohoitaja Mirja Parikka kertoo, että jos työntekijöitä sairastuu vielä lisää, on viikonlopun työvuorojen järjestäminen vaikeaa."

Tämä Pohjois-Karjalan epidemia tuskin on lintuinfluenssaa. Mutta olisipa äärimmäisen noloa, jos Suomessa löydettäisiin ensimmäiset lintuinfluenssatapaukset siten, että vuodeosastollinen ihmisiä kuolisi siihen. Ehkä tosiaankin kannattaisi edes vähän etsiä sitä H5N1-virusta eläimistä...
Tiesittekö muuten, että terveyskeskuksissa influenssatesti ei ole millään lailla rutiinitutkimus. Influenssatestit tehdään kuulemma Kansanterveyslaitoksen erityisprojektin puitteissa ja vain muutamissa terveyskeskuksissa.

"Tohmajärven epidemian syy yhä epäselvä
Hanna Koivisto 18.5.2006, 12:03
Tohmajärvellä etsitään edelleen syytä terveyskeskuksen vuodeosastolla viikonloppuna puhjenneeseen hengitystietulehdusepidemiaan. Torstaihin mennessä sairastuneita oli jo 24, heistä 15 hoidossa olevaa potilasta ja 9 terveyskeskuksen hoitajaa. Terveyskeskuksessa on yhteensä 40 potilasta ja 27 työntekijää.
---
Taudin oireet ovat yskä, kuume ja hengenahdistus. Joidenkin potilaiden tulehdusarvot ovat nousseet erittäin korkeiksi ja muutamalla on todettu keuhkokuumetta.
---
Taudin aiheuttajan selvittämiseksi otetut verinäytteet ovat tutkittavana. Myös terveyskeskuksen vesijohtovesi ja ilmastointi tutkitaan. Tutkimuksiin osallistuvat terveyskeskuksen lisäksi lääninhallitus, keskussairaala ja kansanterveyslaitos."

****

"Hengitystietulehdus 24 tohmajärveläisellä
17.5.2006 19:24
Kolmasosa terveyskeskuksen hoitajistakin sairaana.
Ärhäkkä hengitystietulehdus on riehunut alkuviikon Tohmajärven terveyskeskuksen vuodeosastolla Pohjois-Karjalassa. Kuumeiseen tulehdukseen on sairastunut yhteensä 24 henkilöä. Sairastuneista yhdeksän on hoitajia ja 15 terveyskeskuksen vuodeosaston iäkkäitä potilaita. Sairastuneet on eristetty terveyskeskuksen yhteen siipeen. Potilailla on kuumeen lisäksi yskää ja hengenahdistusta.
- Osalla potilaista tulehdusarvot ovat kohonneet ja yleiskunto on laskenut.--- kertoo Tohmajärven terveyskeskuksen johtava lääkäri Markku Savola. ---"

"Seven members of a family in Kubu Simbelang village in north Sumatra were infected with the H5N1 virus and six of them died between May 4 and 12. But experts and local health authorities have come no closer to finding the culprit.
"This case shows surveillance work should intensify. When there are human infections, you have to find the source. It's too slow," said microbiologist Guan Yi, who has studied the H5N1 virus since it made its first known jump to humans in Hong Kong in 1997. "Early detection in animals is essential."
"If it was a pandemic strain, we'd be finished," he said."

Tiedetäänkö vielä mistään, ettei juuri tämä Kubu Simbelang -kylän virus olisi pandemian aiheuttava virustyyppi? Taitaa olla liian aikaista huoahtaa helpotuksesta.

"H5N1 spread among people not ruled out
By Tan Ee Lyn
Wed 17 May 2006
According to the World Health Organisation and experts familiar with the case, the family - which raised a small number of pigs and had chickens, ducks and geese in the neighbourhood - held a barbecue on April 29 when they ate pork and chicken.
The first person to fall ill was a 37-year-old woman, and two of her sons, her brother, sister, niece and nephew later fell sick. Except for the woman's brother, everyone has since died.
---
The 37-year-old woman fell ill on April 27, while one of her sons and her sister - the last ones to fall sick - felt the first symptoms on May 5. The WHO recommends that an incubation period of seven days be used for field investigations.
"If they were all infected by the same source, their onset time (of illness) would have been closer, but that is not the case ... The later cases may involve the possibility of human-to-human transmission," Guan told Reuters.
"They may have infected one another ... but we have no evidence. This needs to be investigated by the locals."
Some reports say chicken manure used as fertiliser might be the link. Infected birds can excrete large amounts of the virus and birds and people can be infected this way."

*** But if the incubation time is about seven days, how come the 37-year old woman fell ill already on April 27, when the barbeque was held not earlier but April 29? Or do the officials mean that the woman was sick already many days before and passed the flu to others when preparing the food? Or what could be a reasonable way to think about it? ...Just wondering.

Medan, N Sumatra (ANTARA News)
May 15 16:25

Coordinating Minister for People's Welfare Aburizal Bakrie early this month said that some 401 suspects of bird flu (avian influenza) had been examined. Of the number, 330 were declared negative with the bird flu virus, 128 were still under observations and 128 had been confirmed positive with the virus.

"--- The incident, now being referred to as the Karo Cluster because it originated in the village of Karo, appears to be growing in scope. Two more members of the family have died, bringing the total death toll within the family to 6. The two latest victims were children; an 8 year old and an 18 month old infant.

But the disease has not stopped at family lines and authorities have been forced into widespread testing. According to posts on Recombinomics, the Indonesian government has had to test more than 600 people. Of these, 356 have tested negative for the H5N1, 128 are under observation and another 128 have tested positive (yes, you read that correctly). So far, the WHO has not confirmed most of these tests. ---"

"The following report has been cobbled together from a combination of news
sources, some local to Sumatra and others international.
A large cluster of H5N1 cases among an extended family in the Indonesian
province of North Sumatra, on the island of Sumatra, has health officials
around the world concerned. Reports from the location have been incomplete
and conflicting, but the following is the best information available as of
Sunday evening.
In a village about 175 kilometres south of the provincial capital of Medan,
7 or 8 members of an extended family were hospitalized more than a week ago
with suspected bird flu. On 12 May 2006, Pengendalian Breakingprep
Penyakit, director general of the North Sumatra Department of Health and
Environmental Sanitation, confirmed that at least 5 of the 8 suspected bird
flu cases had tested positive for the H5N1 virus in local testing. Samples
have been sent to a WHO-affiliated lab in Hong Kong for verification.
Some local news sources stated that the family lived in the same small
home, while other sources indicate that they lived close to one another in
the same village, but in different homes. In any case, the family was taken
to Medan (the provincial capital) for hospitalization at the RSUP (Central
Public Hospital) Adam hospital.
The first death to come to the attention of the international community was
[a 19 year old man, the index victim], who died Tuesday, 9 May 2006, 11
days after first showing symptoms. His mother, [40 years old], had died on
4 May.
On Wednesday, 4 May, a woman aged 29 died at the hospital at about 5 a.m.
local time. Her relationship to the others has not been clearly stated,
though there is some indication that she may have been an aunt of the 19
year old man. She was identified by some local sources as living in
Kabanjahe, the capital of the Karo Regency (district), and not in the
village where the others lived, but the accuracy of this last statement is
not known.
A 18 year old man, brother of the index victim, died on 12 May.
A boy, age 8 (some sources said 10), died Saturday, 13 May, at about 2 p.m.
local time, at RS Elizabeth hospital, also in Medan. This may be the
individual identified by some news sources as a cousin of the index man, a
child aged 8. This also may be the source of reports that 8 members of the
family were hospitalized, rather than the 7 for whom we have identification.
A baby boy aged 18 months was originally reported as having died on Friday
12 May, but it was later learned that he did not die until Sunday 14 May.
This date of death was confirmed Sunday by I Nyoman Kandun, director
general of disease control at the health ministry.
On 13 May, local media reported panic in the region (but, if there were
panic, it likely was in the Karo district rather than in Medan itself).
They also reported that the 2 surviving members of the original family were
transferred to RS Elizabeth after they attempted to flee the hospital. The
accuracy of these reports of attempted flight have not been verified, but
it is known that the 2 survivors (not the toddler) were transferred to RS
Elizabeth, where one of them died on 13 May. Other sources reported that
the 2 were released from hospital, but hospitalized again after their
conditions became worse. This last report seems far more unlikely than that
they attempted to flee.
Both local and international media reported that one or more family members
originally contracted the disease from contact with contaminated
fertilizer. According to local sources, the family often bought manure from
2 unidentified vendors whose poultry had recently been found positive for
the H5N1 virus.
On 12 May, in addition to reporting 2 deaths (one of which did not happen),
local sources also reported that 12 people remained hospitalized in RSUP
Adam with suspected bird flu symptoms. It was not stated if these people
were other relatives, friends and neighbors, or just what their exact
association with them was.
These sources also reported that, worried by the spread of the disease, the
provincial government of North Sumatra ordered the Karo district health
service to sterilize the family's home along with an area of 1 kilometre
radius surrounding it. This also means culling or vaccinating all poultry
in that area.
WHO officials in Indonesia said Sunday that tests of livestock in the
village showed positive results for the H5N1 virus and now poultry and
swine in the village are being tested. No indication was given if by
"livestock" the WHO meant cattle, nor why (if it does mean cattle) these
animals were tested before poultry and swine, both of which have stronger
indications for infection than do cattle.
This outbreak is the largest familial cluster reported in Indonesia to
date. It also may be the largest familial cluster ever reported for the
H5N1 virus and has international health officials worried that the disease
may be mutating to become more easily transmitted between humans.
H5N1 has been in Indonesia since 2003. The first human infections, however,
were only reported in 2005.
There are many issues involved in getting news of this outbreak out of
Medan and North Sumatra. First, is the problem that local news sources are
all in Indonesian, which not only is a different language, but even has a
different character set (alphabet) from English. Second, the accuracy of
local news sources is highly questionable. Third, both hospital and
government officials may not always be forthcoming with information about
victims or the course of the disease.
Readers also should be aware of the following language issues with reports
coming out of the North Sumatra area: Karokaro is sometimes transliterated
as Karakar or as Karo-karo; Beru is sometimes transliterated as Boru, and
is often abbreviated as Br."

"Hengitystieinfektioissa virusta ja sen antigeenisia osia erittyy nenänielueritteeseen, jossa niiden määrä varsinkin taudin alkuvaiheessa voi olla suuri. Antigeenin osoituksen diagnostinen herkkyys on lasten infektioissa hyvä, mikäli näyte otetaan n. 5 vrk:n kuluessa taudin alusta. Sen jälkeen virusantigeenien määrä nenänielussa on selvästi laskenut. Aikuisilla herkkyys on huonompi, mutta etenkin influenssa- ja adenovirusinfektioissa menetelmä on silti käyttökelpoinen."

"A total of 327 samples were obtained; 36 were positive for influenza A by rapid test, and all but 2 grew the organism on tissue culture with a positive predictive value of 94%. Nineteen specimens were negative by rapid test, but grew influenza A on tissue culture with a sensitivity of 64%."

* Does this mean, that for every two positive H5N1-results there are one negative that in fact is positive?

* Another view:

"A variety of antigen-capture assays are commercially available for the detection of influenza. In addition, real-time multiplex polymerase chain reaction (PCR) has been used to detect influenza A and B in clinical specimens. The commercial assays can be completed in less than 30 minutes and have a sensitivity of at least 70% and a specificity of 90%, compared with viral isolation."

* And what is the sensitivity of viral isolation tests?

* The best test algorithm of current knowledge?:
"--- The sensitivity and specificity of the microneutralization assay were compared with those of an H5-specific indirect ELISA. When combined with a confirmatory H5-specific Western blot test, the specificities of both assays were improved. Maximum sensitivity (80%) and specificity (96%) for the detection of anti-H5 antibody in adults aged 18 to 59 years were achieved by using the microneutralization assay combined with Western blotting. Maximum sensitivity (100%) and specificity (100%) in detecting anti-H5 antibody in sera obtained from children less than 15 years of age were achieved by using ELISA combined with Western blotting. This new test algorithm is being used for the seroepidemiologic investigations of the avian H5N1 influenza outbreak."

"Indonesia probes bird flu cluster; WHO alerted
15 May 2006 14:49:51 GMT
Source: Reuters

JAKARTA, May 15 (Reuters) - Indonesia is investigating an outbreak of H5NI bird flu in up to eight members of a North Sumatran family, six of whom have died, Agriculture Minister Anton Apriyantono said on Monday.

Five of the eight, including four of the dead, showed positive for avian flu in local tests, while three other family members were suspected cases, the minister said.
Apriyantono added that the deadly virus had not yet been found in local poultry, which is normally the source for infections in humans.
In Geneva, the World Health Organisation (WHO) said it was following the case closely because of the possibility of human-to-human infection.
---
"It is something we are taking very seriously," said WHO spokeswoman Maria Cheng about the Indonesian case. "Any time we have a possible cluster it raises suspicions that human-to-human transmission may have occurred," she told Reuters.
---
"It may be that these people had common exposure, it may be that they caught the disease taking care of family members. Right now we do not know, but it is something that has caught our attention," she said.
---
An Indonesian health ministry spokeswoman said blood samples of the five people who had tested positive locally had been sent to a WHO-affiliated laboratory in Hong Kong for confirmation. Local tests are not considered definitive.
The WHO also sent a team to North Sumatra to investigate the case, said Sari Setiogi, a spokeswoman for the agency.
'So far, an examination of chickens, ducks and pigs around the victims' houses has turned out negative,' Apriyantono told reporters on the sidelines of a Food and Agriculture Organisation meeting in Jakarta."
*****
Aika monta ilmeistä väärää negatiivista. Mikä mahtaa olla paikallisesti tehtävän H5N1-testin herkkyys?
Quite many apparently wrong negative results. Just wondering, what is the sensitivity of the local H5N1 tests?

"Russia (Novosibirsk), poultry
Date: Thu, 11 May 2006
From: Joseph Dudley
Source: Itar-Tass, 10 May 2006 [edited]
Bird flu has been registered in the Kochkovo district, the
Novosibirsk region, Siberia, the head of the Russian agriculture
watchdog [agency], Sergei Dankvert, told Itar-Tass on Wednesday.
"H5N1 virus has been found in non-vaccinated poultry in private
households of the Reshety village," he said. [Latitude 54.2142 Longitude 80.2142; map at
http://www.fallingrain.com/world/RS/53/Reshety.html.

So far the flu has killed 64 birds. The village has 35 000 poultry,
Dankvert said.
Bird flu has been [recently] registered in Russia's 6 villages, 4 of
them in Dagestan, one in the Krasnodar Territory and another one in
the Novosibirsk region.
As of 5 May 2006, 65.3 million doses of anti-bird flu vaccine was
delivered to Russia's regions. Almost 33 million birds were
vaccinated all over Russia.
--
Joseph P Dudley, PhD
Chief Scientist
Biosecurity and Bioinformatics
EAI Corporation


[The first H5N1 outbreak in Siberia was reported in Novosibirsk
during the 3rd week of July 2005. The H5N1 virus, which affected
domestic poultry, was also isolated from wild birds (ducks, grebe).
The epizootic spread to 9 other regions (Altai, Astrakhan,
Chelyabinsk, Kalmykia, Kurgan, Omsk, Tambov, Tiumen and Tula),
causing 62 outbreaks (of which 15 -- the highest number -- in
Novosibirsk). The involvement of domestic poultry was terminated at
the end of October 2005. The annual data were summarised in Russia's
follow-up report No 5 of 27 Dec 2005. At that time, vaccination was
prohibited in Russia.

An "Immediate notification report", sent on 16 Feb 2006, notified the
renewal of AI outbreaks in commercial poultry, this time in Dagestan;
they were followed by outbreaks in other parts of southern Russia
(Stavropol, Volgograd, and Krasnodar). In March 2006, the Russians
decided to apply mass vaccination (see 20060311.0771).

A Russian epidemiologist, Gennady Onishchenko, was quoted on 25 Apr
2006 saying that the epicenter of the bird flu virus has shifted to
Russia, and that uninfected migrating birds would reach Siberia and
the Ural Mountains by the end of April and "probably become infected
by the summer" (see 20060426.1215). - Mod.AS]"

"Jurmossa löytynyt satoja kuolleita sepelkyyhkyjä ja töyhtöhyyppiä
Julkaistu: 8.5.2006 20:16
Helsingin Sanomat
KORPPOO. Korppoon Jurmosta on löytynyt pääsiäisen jälkeen satoja kuolleita sepelkyyhkyjä ja töyhtöhyyppiä. Jurmon asukkaiden mukaan mitään vastaavaa ilmiötä ei ole saarella tapahtunut koskaan aikaisemmin.
Viimeisimmät linnut ovat kuolleet noin viikko sitten, mutta niitä lojui vielä maanantaina pitkin ja poikin saaren polkujen varsilla. Saarelaiset ovat polttaneet ja kuopanneet jo kymmenittäin lintuja.
Ensimmäisenä heti Jurmon tunnetussa vierasvenesatamassa tulijaa tervehti siivet levällään makaava kuollut joutsen. Matkalla kohti Jurmon kylää näkyi tienvarressa heti kuolleita töyhtöhyyppiä. Kylässä lojui keskellä talojen kotipihoja vielä suhteellisen tuoreita kuolleita sepelkyyhkyjä.
Varsin ankea näky kohtasi kylän vieressä olevassa kitukasvuisessa männikössä, jossa oli joka puolella ympäriinsä levinneitä sepelkyyhkyjen höyhenkasoja ja raatoja.
Jurmossa asuva Pirjo Mattsson kertoo asuneensa saarella jo 27 vuotta, mutta ei ole koskaan ennen nähnyt mitään vastaavaa. Hän kertoo laskeneensa jo ennen pääsiäistä 32 sepelkyyhkyn ja töyhtöhyypän raatoa. Kun hän käveli viimeksi polkua rantaa pitkin rantaa entisille verkkopaikoille, hän laski matkalla 24 raatoa.
Kaikki kuolleet linnut ovat olleet töyhtöhyyppiä ja sepelkyyhkyjä, kuolleita vesilintuja Mattsson ei ole havainnut ainuttakaan venesataman joutsenta lukuun ottamatta. Hänen mukaansa kuolleita lintuja on kaikkiaan satoja.
Jurmon saarella asuu tällä hetkellä neljä kettua ja niillä on ollut Mattssonin mukaan pulskat päivät, kun ne ovat levitelleet ja raahanneet kuolleitten lintujen raatoja ympäriinsä. Saarelaiset ovat seuranneet ikkunoista, kun pikkuketut ovat leikkineet aivan kotipihojen pellolla sepelkyyhkyjen kanssa.
Kuolleita lintuja ei ole voinut lähettääkään minnekään, sillä posti ei ole ottanut niitä kuljetettavaksi eikä saarelaisilla ole kulkuneuvoja, millä niitä kuljettaisi.
Kuolleita joutsenia Jurmossa oli Lindströmin mukaan tänä keväänä 25 kappaletta. Läänineläinlääkärin piti käydä niitä katsomassa, mutta hän ei päässyt oikeaan paikkaan vaikean jäätilanteen takia."

Jurmo island, archipelago Finland

"De döda Jurmo-fåglarna testas
09.05.06 21:34

Orsaken till den stora fågeldöden på Jurmo klarnar kanske imorgon på eftermiddagen.
Åtminstone borde man då få besked om det kan vara den aggressiva formen av fågelinfluensa H5 som finns i de fåglar som nu testas. Att få reda på andra sjukdomar som till exempel salmonella tar betydligt längre tid.
En privat pargasföretagare har tagit saken i egna händer och idag på morgonen transporterat ett antal döda småfåglar till forskningsanstalten för veterinärmedicin och livsmedel i Helsingfors (Eela). Pargasföretagaren säger sig inte ha någon koppling till varken fåglar eller Jurmo men känner till skyddsutrustning och förfaringssätt och tyckte att fåglarna måste undersökas.
Utflykten till Jurmo i båt och bilresan till Helsingfors kostade mannen cirka 1000 euro."

Crofsblog 5.5.2006:
"The New York Stock Exchange gets serious
The New York Stock Exchange has sent an information memo to all its member organizations: Guidance pertaining to business continuity and contingency plans relating to a potential pandemic.
'Although there is no pandemic flu at this time, were one to occur, it may cause a significant and extended business interruption differing materially from the emergencies recently confronted by member organizations of the New York Stock Exchange LLC (the 'Exchange').
For example, a pandemic flu is expected to occur in multiple 'waves,' each potentially spanning weeks or longer, and thus might have a substantially greater duration than the blackout of August 14 and 15, 2003, or the terrorist attacks of September 11, 2001.
In addition, a pandemic flu is expected to involve outbreaks in numerous domestic and international locations. Therefore, unlike the regional emergencies created by Hurricanes Katrina and Rita, a pandemic flu might impact a member organization’s main office, branch offices, back-up locations, suppliers, and customers, regardless of their geographic diversity. '

And so on. I especially like the understatement of a pandemic having 'substantially greater duration' than a two-day blackout.
The whole memo is available online and as a PDF. It's worth reading the whole thing. When the Masters of the Universe take this science-fiction stuff seriously, it's serious."

Suomellahan on ollut varsin hyvä tuuri, ettei meillä ole tiettävästi yhtä ainuttakaan H5N1-tapausta, vaikka Ruotsissa ja Venäjän Arkangelissa on jo montakin...

Isn't it great that in Finland we don't have even the slightest hint of any cases of H5N1 even though there are already many in Sweden and Archangelsk, Russia...

"H5 Antibodies in Wild Goose in Northwest Russia
Recombinomics Commentary
May 6, 2006
http://www.recombinomics.com/News/05060602/H5_NW_Russia.html
H5 bird flu antibodies have been found in the blood of a wild goose shot for testing outside Arkhangelsk, Nikolai Yuferev, the chief expert from the Arkhangelsk regional veterinary department, told Interfax.
The finding of H5 antibodies in northwestern Russia is cause for concern. Although the antibodies could be from low pathogenic avian influenza, the likelihood that it is the Qinghai strain of H5N1 is high. Last year Russia's OIE Mission report described 24 species (wild duck, laughing gull, rook, northern stover, crow, pigeon, sandpiper, oyster catcher, little grebe. black-winged stilt, phalatrope, little tern, pied wagtail, green sandpiper, white headed plover, starling, coot, mallard sparrow hawk, buzzard, turtle dove, garganey, teal) that had H5N1. These birds had also been shot out of the sky by hunters and demonstrated widespread H5N1 in Russia. The report also indicate that testing in sparsely populated regions had been limited, and the H5N1 infections were more common than indicated in the report.
The recent report of H5N1 in two counties in Qinghai province in China also raised the possibility that H5N1 is again migrating to the north. Arkhangelsk is in the East Atlantic Flyway, which connects Russia to North America, as well as western Europe and western Africa. The Qinghai stain of H5N1 has recently been reported in wild geese in both of these regions, further suggesting that the Russia result was linked to H5N1.
The latest data suggests that H5N1 will soon be detected in North America, adding to the global reach of H5N1."

Olisipa mielenkiintoista tietää, paljonko Suomessa on havaittu muita lintuinfluenssoja kuin H5N1:stä...
It would be quite interesting to know how many bird influenza cases other than H5N1 have been found in the Finnish bird flu tests...

"YLE Teksti-TV
5.5.2006
http://www.yle.fi/cgi-bin/tekstitv/ttv.cgi/html?PAGE=105
Siipikarjan karanteeni lieventymässä
Lintuinfluenssan leviämisen estämiseksi määrätty siipikarjan karanteeni lievenee, Keskisuomalainen kertoo.
Maa- ja metsätalousministeriössä valmistellaan lehden mukaan muutoksia asetukseen, jolla siipikarja määrättiin sisätiloihin tämän kuun loppuun saakka. Jossain muodossa rajoitukset säilyvät.
Ministeriön elintarvike- ja terveysosaston apulaisosastopäällikön Mikael Karringin mukaan lievennyksiin päädyttiin, koska lintuinfluenssatapauksia ei toistaiseksi ole Suomessa ollut.
Edelleen pidetään kuitenkin mahdollisena, että tapauksia tulee."

Free translation to English:
"YLE text TV
5.5.2006
http://www.yle.fi/cgi-bin/tekstitv/ttv.cgi/html?PAGE=105
Ministry easing quarantines of poultry industry
The poultry quarantine ordered for preventing the spread of bird flu is being eased, tells the newspaper Keskisuomalainen.
The ministry of agriculture and forestry in Finland is preparing changes to the statute by which the poultry was ordered to be kept indoors until the end of this month. Yet the regulations are intended to be remained valid in some form also in the future.
The assistant director of the department of food and health, Mikael Karring says that the ministry ended up easing the regulations, because there have not been any cases of bird flu in Finland this far.
However, it is still thought to be possible that some cases of bird flu could emerge in Finland in the future."

"Recombinomics Commentary
May 5, 2006
http://www.recombinomics.com/News/05050601/H5N1_Serious_Flaws.html
``The peak transmission either in poultry or to humans is in the winter months,'' said Robert Webster, the Rosemary Thomas professor at St. Jude Children's Research Hospital in Memphis, Tennessee.
The above comments on avian influenza infections raise serious questions about the surveillance of H5N1 bird flu worldwide. The data from Britain is particularly striking because the detail indicate testing was throughout the peak period in the fall and winter, yet virtually no avian influenza was found in dead or living wild birds.
Avian influenza in birds is common. Testing in Canada of young mallards in August, 2005 found low pathogenic H5 throughout southern Canada. H5 was detected in 24% of the birds tested in British Columbia and as many as 50% of the tested birds had some strain of avian influenza.
Test results from Britain indicate samples were collected throughout the winter months. Only two positives were obtained from live birds, although over 3000 birds were screened. Attempts to isolate virus from the two positives failed.
In dead birds, there was one positive, H5N1, in a whooper swan in Scotland. Again over 3000 dead birds were tested.
Positive data on 3 birds out of 7000 indicates the surveillance methodology was seriously flawed. These flaws were further supported by the H7N3 outbreak in at least farms near Norwich. No H7 was detected in the surveillance samples, again highlight a high rate of false negatives.
Collection and storage flaws may have contibuted to the false negatives reported by DEFRA. However, false nagatives can be generated at many points in the collection and storage process. Countries reporting no positievs in thousands of samples have serious issues.
Many countries in Europe detected H5N1, indicating H5N1 had migrated into the region in the fall of 2005. As indicated by the positive whooper swan in Scotland, H5N1 was in long range migratory birds and therefore would have spread widely throughout the area. However, many European countries still claim no H5N1 infections. No country, other than Russia has detected H5N1 in live wild birds.
These data further demonstrate that the enhanced surveillance in Europe and throughout the world is seriously flawed. The reports of false negatives do little to blunt the spread of H5N1. Countries testing thousands of birds and finding no avian influenza have a serious sensitivity and selection problem.
Issues of false negatives in H5N1 have been obvious since early 2004. The failure to adequately address the failed surveillance remains scandalous."