Penumbra Pandemia

EV71: China tries to calm fears
April 30, 2008 at 08:35 AM
Crofsblogs H5N1
Via the Guardian Unlimited: China tries to calm fears over virus outbreak. This is of interest because it shows how China is detecting and responding to unexpected diseases. Excerpt:

The Chinese government has dispatched medical experts to eastern Anhui province in a bid to curb a rapidly spreading outbreak of an intestinal virus that has killed at least 20 children.
But officials sought to calm fears amid reports that almost 1,900 children have been taken ill with enterovirus 71, or EV71, which can cause hand, foot and mouth disease.
Newspapers have published scathing criticism of local officials, attacking them for waiting weeks to raise the alarm, and even calling for them to be sacked.
The issue is particularly sensitive because of the uproar caused by the authorities' handling of the Sars epidemic of 2003. Then, they sacked the health minister and pledged to construct an "open and transparent" reporting scheme after it emerged that they had not told the World Health Organisation (WHO) of the outbreak until news emerged independently.
Today central government officials said the outbreak could not be compared to Sars and added that it had taken time to discover the cause of the outbreak.
'You can't talk about EV71 and Sars in the same breath. Sars was a new infectious disease, and anyone could be infected. Sars was also very deadly,' Yang Weizhong, deputy chief of the Chinese Centre for Disease Control and Prevention, said in a webcast.
'In the initial stages of [this] probe a lot of effort was expended, to rule out some serious infectious diseases like Sars, bird flu and meningitis,' he added.
The first cases of EV71 emerged in Fuyang city in early March, but the outbreak was only reported on Sunday - 40 days later. Since then, the number of recorded infections has soared, with hundreds more emerging daily and reports of cases in neighbouring Henan province."
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If: "'You can't talk about EV71 and Sars in the same breath. Sars was a new infectious disease, and anyone could be infected. Sars was also very deadly,' Yang Weizhong ---"
Then why: "'In the initial stages of [this] probe a lot of effort was expended, to rule out some serious infectious diseases like Sars, bird flu and meningitis,' he added.
The first cases of EV71 emerged in Fuyang city in early March, but the outbreak was only reported on Sunday - 40 days later."
It seems that the Chinese official is saying that the disease (EV71) was remaining unidentified, that is, a new infectious disease for whole 40 days before the Chinese bothered to alert the rest of the World.

"Bird flu drill gives residents golden lesson
Emmy Fitri
The Jakarta Post
Jembrana, Bali
Sun, 04/27/2008 12:48 PM
There's no such thing as 'bird flu' in Dangin Tukad Daya village in Jembrana, about two hours' drive west of Denpasar. The avian influenza has become Flu Yang Mematikan (deadly influenza), the words splashed across banners of various sizes placed at eye-catching spots throughout the village.
The banners seem to give a hint of what's in store.
On Friday, some residents complained of severe respiratory problems and other cold symptoms. A laboratory check confirmed they had avian influenza caused by H5N1 -- originally a poultry disease.
When one villager reported his chickens had died, officials from the local animal husbandry agency came to examine the carcasses: bird flu was confirmed. The officials took the standard procedure of culling all chickens in a 1 kilometer radius from the infected backyard farm.
In the afternoon, Jembrana Regent I Gede Winasa publicly announced an extraordinary situation after receiving reports from virology and epidemiology tests on the incidents.
By Saturday, 20 villagers had caught the influenza and were rushed to nearby hospitals. Many others were given antiviral prophylaxes to prevent widespread illness.
Health Minister Siti Fadillah Supari declared the village an avian influenza epicenter, which meant get-tough measures were required, such as quarantining the infected residents and shutting off access to and from the village. The school was closed and the students were sent home. Local administration officials distributed supplies for the quarantined families.
---
Everything went as planned in the scenario with residents showing a degree of candor and the necessary spontaneity to play their roles.
The village is hosting a three-day bird flu pandemic drill, which started Friday. About 1,000 people were involved in the drill, which was funded by the Atlanta-based Centers for Disease Control and Prevention.
---
Since reporting its first human case of bird flu infection in 2005, Indonesia has led the world's human bird flu death toll with a staggering 107 deaths. Two of the fatalities were in Bali.
One of the victims was a resident of Dangin Tukad Daya, while the other was from Tabanan. The drill, therefore, was warmly welcomed by the administration and most of residents.
Putu Arini -- who played a wife whose husband became the first patient reported to a community health clinic -- said she was glad she was involved in the drill.
'It (the simulation) will surely be useful. I learned about bird flu after a villager died of bird flu last year. We were told then not to keep free-range chickens. I haven't had any chickens since then. ---'
---"

Why bird flu? Why a pandemic simulation?
Emmy Fitri
The Jakarta Post
April 27, 2008
Jembrana, Bali
"--- On Friday, the Health Ministry started a pandemic simulation in Bali. The simulation kicked off at Dangin Tukadaya village, two hours' drive west of Denpasar. The village is home to 4,300 people. Last year, the village reported two human deaths from bird flu.
The Health Ministry's head of infectious disease control directorate, Tjandra Yoga Aditama, is in charge of the simulation.
For the simulation scenario, he said, the H5N1 has been transmitted from human to human, making the village the pandemic's epicenter.
Jembrana regent is slated to announce the condition to the media, while the Health Ministry has the authority to declare the situation after receiving confirmed laboratory results from virology tests.
'People are banned from leaving their houses to prevent the infection spreading, chickens are culled and the antiviral prophylaxis is distributed to the masses,' said Tjandra.
---
More than 66 million people in Indonesia could be affected by the disease if a pandemic occurs, according to official estimates.
Furthermore, there would be tremendous economic and social losses; those infected would not be able to maintain their usual economic activities and there would be widespread unrest with people fighting over antiviral medicine, hospital beds and information from authorities. The economic and social losses have not yet been quantified.
Chief executive of the National Commission for Avian Influenza and Pandemic Preparedness, Bayu Krisnamurthi, said such a simulation was urgently needed in Indonesia in order to evaluate the newly completed National Pandemic Plan.
The country is now in phase three, said Bayu citing the World Health Organization. During this phase the disease can be transmitted from animal to human but not from human to human.
Earlier this year, at least two pandemic simulations were held on a much smaller scale in Serang and Tangerang of Banten province. Other countries, like Singapore and South Korea, have held similar pandemic simulations using computers. They didn't, however, involve real life conditions.
'We plan to have at least eight simulations on various scales throughout this year,' he said.
---
The virus is endemic in Indonesia's sprawling islands, where the majority of the population depend on agriculture for their livelihood.
---
Only three of the country's 33 provinces have not reported any bird flu cases among poultry.
'Since it's endemic and has been here all along, we need to find ways to live with it. It's literally in our hands,' Bayu said.
Hand-washing campaigns have begun. In most human cases of avian flu, the victims had been in direct contact with a sick or dead ---.
Indonesia has the highest number of human deaths from avian influenza, reaching 107 this week. Worldwide, 350 people have been infected with the disease.
---
Poor sanitation is frequently cited by officials as the major contributor of human deaths from the virus.
There is no cure for the virus if detected too late as it ravages the lungs within a matter of days. However, the antiviral oseltamivir, if taken within the first two days, can save lives.
The symptoms at the onset of avian influenza are similar to those of the common cold, making detection difficult. Once it gets worse, detection becomes easier as severe pneumonia starts to occur.
A decade after bird flu's emergence, several cases worldwide were categorized as human-to-human cases, known as cluster cases. This shows the possibility of human-to-human transmutation exists and is not a matter of how but when.
Indonesia needs to be prepared for the possible pandemic. Louis Pasteur said in his book The Demon in the Freezer, 'Chance favors the prepared mind.'"

"Soldier With Mild Confirmed H5N1 Raises Pandemic Concerns
Recombinomics Commentary 15:08
April 22, 2008
Tests have shown that the virus detected in the patient's body was an H5 strain, according to the Korea Center for Disease Control and Prevention. It will take up to three weeks for a lab to confirm whether or not the strain is the deadly H5N1 strain, which has caused massive outbreaks in the Jeolla region since April 1.
The young corporal, identified only by his family name Cho, was sent to help kill infected chickens and ducks on Friday and Saturday. He suffered from high fever and was transported to an army hospital Sunday.
Authorities said his sickness was not related to the bird flu and that his condition has improved.

The above comments provide more detail on the H5N1 infected soldier in South Korea. The 'H5' designation for the soldier is similar to comments on the H5 infected birds in South Korea. There is no data supporting anything other than H5N1 for the outbreaks in South Korea. In the OIE report, some were H5N1 confirmed while others were HPAI H5 confirmed at the time of filing. No H5 had been confirmed to be low path H5.
The rapid recovery could have been due to both antibiotic and Tamiflu treatment, if the patient had secondary bacterial pneumonia. However, the bacterial infection does not invalidate the H5 detection.
More detail on how the soldier was infected would be useful. Pictures of culling operations showed cullers in PPE’s from head to toe. Moreover, cullers are usually on prophylactic Tamiflu (oseltamivir).
The denial of the associated of bird flu symptoms with H5N1 infections raise concerns of additional H5N1 patients that are not considered H5N1 infections because of arbitrary and capricious definitions. The infected culler also raises concerns about infected farmers who have not used PPE’s or Tamiflu.
The H5 positive result raises concerns of widespread mild H5N1 patients in South Korea as well as Bangladesh and India. The passage of H5N1 through human hosts increases the likelihood of human adaptation and efficient transmission.
More information on the patient, PPE’s and prophylaxis would be useful."

Indonesians hold major drill for bird flu pandemic
BALI, INDONESIA
Friday, April 25, 2008 at 10:09 a.m.
AP
"Indonesia launched a major bird flu drill Friday [April 25, 2008] that will test the ability of the nation hardest hit by the virus to respond to a possible pandemic. Thousands were taking part, from local residents to government officials.
The three-day simulation started with the isolation of a village on the resort island of Bali, where a field hospital was being set up to treat people with flu-like symptoms. Before the drill ends Sunday, officials will try to prevent 'infected' travelers from leaving the international airport and spreading the virus to other countries.
'This is a very important event from the perspective of public health,' said Subhash Salunke, of the World Health Organization. ---
Indonesia has been worst affected by bird flu since it started ravaging Asian poultry stocks in late 2003, with its 107 human deaths accounting for nearly half the 240 recorded fatalities worldwide. The government has come under fire for failing to slow the spread of the virus, which is now endemic in poultry in all but two of the countries' 33 provinces.
---
Indonesia says there are limits to what its cash-strapped government can do.
---
scientists worry it could mutate into a form that spreads more easily between humans, with the potential to kill millions worldwide. Indonesia is seen as a potential hotspot for that to happen.
That makes the drill on Bali especially relevant, said Nyoman Kandun, a senior health ministry official. More than 5,000 people were taking part, from government officials and law enforcement officers to doctors and villagers. ---"

"Outoja lintukuolemia Keski-Pohjanmaalla
STT via Plaza.fi
17.4.2008, 18.03 (päivitetty 18.05)
Keski-Pohjanmaalta Kaustiselta on löytynyt kymmeniä kuolleita lokkeja.
Biologi Harri Hongell Länsi-Suomen ympäristökeskuksesta vahvistaa, että turkistarha-alueen läheltä on löytynyt parin päivän aikana nelisenkymmentä kuollutta lintua. Kaustisen kunta on tehnyt asiasta poliisille rikosilmoituksen.
Elintarviketurvallisuusvirasto Evira selvittää lokkien kuolinsyyn."
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Briefly in English:
Dozens of dead seagulls have been found in Kaustinen area, Finland. Biologist Harri Hongell from the environment agency of Western Finland confirms that about 40 dead birds have been found near a mink farm in Kaustinen. The town of Kaustinen has called for police to investigate the reason for the dead birds. Also the Finnish food safety authority Evira is going to investigate the dead birds.

A large flock of about 70 dead seagulls have been found in Kaustinen area in Finland.


A new law about handling sick animals in public facilities and in nature is being proposed in Finland.

"Bird Flu Case Raises Fears of Undiagnosed Infections
China
April 11, 2008
A new case of human-to-human transmission --- reinforces fears that there could be many more undiagnosed human infections in China. It may also point to a potential cure.
Last November, a salesman hospitalised in Nanjing, China, with fever, diarrhoea and pneumonia was given antibiotics for suspected bacterial infection, but tested positive for H5N1 shortly before he died. The next day his father fell ill with a nearly identical virus, and was given plasma from a woman who had received an experimental whole-virus H5N1 vaccine. He recovered (The Lancet, DOI: 10.1016/S0140-6736(08)60493-6).
The month before, an H5N1 patient in Shenzhen also recovered after receiving plasma from someone who had survived the infection, suggesting that antibodies from such survivors are a promising approach to treating H5N1, and should be investigated further.
However, poultry in Chinese markets are required to be vaccinated, and the fact that the Nanjing salesman had visited a live poultry market shortly before he fell ill reinforces fears that many Chinese could be getting H5N1 from vaccinated poultry, which carry the virus but remain healthy. Like the salesman, such people could be misdiagnosed because they have not been near sick birds.
Jeremy Farrar of the University of Oxford's Clinical Research Unit in Ho Chi Minh City, Vietnam, says scientists should study family clusters of H5N1 to learn what allows the virus to infect humans. ---"

"H5N1 Fatality Confirmed in Depok Indonesia
Recombinomics Commentary 13:48
April 6, 2008
The bird flu virus yesterday claimed the Rivera life not the name in fact 16 years, the resident of the Pengasinan District, Kecamatan Sawangan, of Depok. This girl was the 108th bird flu sufferer in Indonesia that died. He blew out the last breath in the Hospital of Penyakit Infeksi Dr Sulianti Saroso, Jakarta.
Casualties's father, Sutisna, 50 years, said the child the three of them that began to be sick since last Tuesday. Rivera often the cough and was difficult to breathe. The 'temperature' of 'his body was also high,' he said.
Sutisna that was increasingly worried brought his daughter to the Hospital of Bhakti Yudha, Depok. There, Rivera underwent treated inap. Two days were treated, the hospital side confirmed his patient was infected by the bird flu virus so as Rivera was sent to the Hospital Dr Sulianti Saroso.

The above translation confirms another H5N1 fatality in Jakarta. The sixteen year old girl lived in Depok, just to south of Jakarta and was hospitalized there prior to transfer to Jakarta, where she died yesterday."

"Large Suspect H5N1Cluster in Central Java Indonesia
Recombinomics Commentary 14:34
April 5, 2008
The seven residents suspect AI have the initials Ar,45, Wh,24, Sn,35, Jm, 40, Dp, 9, Hn, 35, and Ks, 34. Dinas Kesehatan (Dinkes) suspected them tertular the virus H5N1 because all the victim experienced the sign similar to bird flu like the cough, breathless, the temperature of the body on 38 Celcius levels, had a headache, and pilek.
At this time, the casualties were still undergoing the intensive maintenance in the Singorojo Community Health Centre.

The above translation describes the hospitalization of seven suspect bird flu patients in Kendal in Central Java, Indonesia. Large clusters are common in Indonesia, and confirmation is limited by Tamiflu treatment. The largest confirmed cluster reported to date in Indonesia was the Karo cluster in Sumatra. The largest unconfirmed cluster was the Garut cluster in West Java.
In the past testing and treatment was largely limited to patients transferred to large infectious disease hospitals. Distribution of Tamiflu to community center, such as the one described above, allows for earlier treatment, but may decrease the number of confirmed cases."

"Confirmed H2H2H H5N1 Transmission in Pakistan
Recombinomics Commentary 17:14
April 3, 2008
The recently released WHO update on the H5N1 transmission in Pakistan in late 2007 confirms it was human to human to human (H2H2H). The transmission chain is supported by disease onset dates, contacts, and laboratory confirmation of three of the four members in the transmission. This chain would match the largest confirmed chain, which involved more family members, but was limited to two distinct transmission events in Karo, Indonesia.
For the Pakistan cluster, the index case was a veterinarian, who was infected while leading a cull of poultry in October, 2007. He developed symptoms on October 29, several days after the cull. He infected one of his brothers who cared for him. The brother developed symptoms on November 12 and died November 19. This brother infected two other brothers, who both developed symptoms November 21. One brother died November 27, while the other brother recovered.
Thus, of the four cases, two died and two recovered. Of these four, three were laboratory confirmed, but only one of the three (the second dead brother) was confirmed with PCR and virus isolation. The other two were confirmed serologically. The first brother to die was not laboratory confirmed and therefore is officially a probable case, based on clinical course, including pneumonia and death.
The latest update should clear up some of the confusion generated by the delays in reporting, false negatives linked to sample degradation, and conflicting and/or confusing statements, due in part to the delays (first media reports were in early January) and degradation.
This cluster also highlights weaknesses in testing. If this was not a cluster, it is likely that only one of the four cases would be confirmed instead of three of four. The three create a cluster, although the link between the index case and two brothers developing symptoms is the first fatality, who was not lab confirmed.
The identification of serious testing shortfalls through cluster analysis is not unusual. Most clusters have one or more aspects which involve false negatives or lack of sample collection / testing.
There are two such recent examples in Indonesia. In both clusters, no sample was collected from the index case, who died, and both clusters have H5N1 confirmed family members. One cluster was specifically denied and the denial was accepted at face value in a Promed commentary. The second index case has not been identified in the English language media. Neither suspect cluster was mentioned in the WHO update on Indonesia.
These failures to confirm obvious H2H in current clusters remains a cause for concern. Similarly, the confirmed H2H2H cluster in Pakistan raises additional questions about failures to report or confirm additional human H5N1 cases in Pakistan, India, and Bangladesh."
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It's the same cluster where one of the brothers took an airplane from Pakistan to New York after attending the H5N1 funerals, got flu-like symptoms on his way, and after getting back to home New York noticed that also his child had flu-like symptoms.

The patients are being tested for antibodies to H5N1. The best target would be the H5N1 in circulation in Pakistan at that time, which was isolated from the first confirmed brother. Therefore, using that H5N1 as a target would generate the most specificity and sensitivity for the antibodies in the convelescent sera of the brothers.
Happily, the Pakistani cluster virus was already grown as for taking the convelescent sera of the New York -based family brother (at least the convelescent sera was claimed to have taken from the US brother). I just wonder why don't they use that one?