Urgency of bird flu in Sumatra lessened

By Peter Gelling The New York Times

THURSDAY, MAY 18, 2006

http://www.iht.com/articles/2006/05/18/news/flu.php

YOGYAKARTA, Indonesia After further investigation, World Health Organization officials said Thursday that the five avian flu deaths confirmed this week on Sumatra were probably not a result of human-to-human infection and did not suggest that the virus had mutated into a more deadly form.

Five family members were confirmed dead from the H5N1 strain of avian influenza by the World Heath Organization on Wednesday, the largest such cluster yet recorded. A sixth family member died of flu-like symptoms but was not tested for the virus.

"We will likely never know the cause of her infection," Maria Cheng, a World Health Organization spokesperson, said Thursday.

Groupings like the one in Kubu Sembilang village in northern Sumatra worry health officials because they indicate the virus may have been transmitted between humans.
Health officials have long feared such a mutation could trigger a worldwide pandemic capable of killing millions.

Continued at link

Blogger reveals China's migratory goose farms near site of flu outbreak

The hypothesis that migratory birds are responsible for spreading avian flu over long distances has taken another knock. Last year, an outbreak of the deadly H5N1 strain in thousands of migratory birds at Qinghai Lake in western China provided what seemed the first firm evidence for the idea. Because the lake is so remote, experts assumed infected birds had flown up from southern China.

But it has now emerged that, since 2003, one of the key migratory species affected, the bar-headed goose, has been artificially reared near the lake. The breeding farms — part of an experimental programme to both domesticate the birds and release them to repopulate wild stocks — raise the possibility that farmed birds were the source of the outbreak.

Roy Wadia, a World Health Organization (WHO) spokesman in Beijing, agrees that, if confirmed, the finding is "important", as changing the breeding practice might help control the infection.

more

http://www.nature.com/news/2006/060515/pf/441263a_pf.html

Tests show Sumatra pigs carry bird flu virus-minister
18 May 2006 05:47:36 GMT
Source: Reuters
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JAKARTA, May 18 (Reuters) - Pigs have tested positive for bird flu in the same village on Indonesia's Sumatra island where five people have been confirmed infected with the H5N1 avian influenza virus, a minister said on Thursday.

The case involving up to seven family members, six of whom have died, has raised alarm around the world because authorities cannot rule out human-to-human transmission.

But the World Health Organisation and Indonesian health officials had been frustrated by the lack of evidence pointing to a source of the virus, usually infected poultry.

The WHO confirmed on Wednesday that five members of the family had contracted H5N1 and tests on a sixth were pending.

Officials had said earlier that on-the-spot testing of various animals living around Kubu Simbelang village in North Sumatra province had given negative results for avian influenza.

However, Agriculture Minister Anton Apriyantono told reporters on Thursday the pig samples from the village had been brought to a leading animal research centre on Java island, and scientists there found a positive result for bird flu.

"After we brought them to Bogor, the serology test found positive results. From 11 pig samples, 10 are positive. Reconfirmation testings are still underway," he said, but did not specify the H5N1 virus.

Bogor is a West Java city where a veterinarian institute is located.

Clusters of human infections are worrying because they indicate that the virus might be mutating into a form that is easily transmissible among humans. That, experts say, could spark a pandemic in which millions might die.

For the moment, the virus is mainly a disease in birds and is hard for humans to catch.

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Denmark has confirmed an outbreak of the lethal H5N1 strain of bird flu on a backyard poultry farm on the island of Funen, the European Commission said on Thursday. The farm consisted of around 100 birds.

http://today.reuters.com/News/CrisesArticle.aspx?storyId=BRU004638

Comment:
It still seems that the virus has difficulties in moving either north or south.

-- There are no income taxes in The Democratic People's Republic of Korea

Bird flu fight must focus on animal infection -FAO

Thu 18 May 2006 7:45 AM ET

http://today.reuters.com/News/CrisesArticle.aspx?storyId=JAK193644

JAKARTA, May 18 (Reuters) - The fight against the bird flu virus should focus on preventing infection in animals to prevent transmission of the disease to humans, a senior Food and Agriculture Organization (FAO) official said on Thursday.

The H5N1 virus remains essentially an animal disease, but it has killed 115 people worldwide, the majority in east Asia since 2003. All victims caught the disease through contact with poultry.

Jacques Diouf, FAO director general, said most global funds so far had been earmarked for preventing a human pandemic, rather than limiting bird flu infection among poultry.

"People are stocking Tamiflu and providing services at hospitals, instead of giving priority to the disease which is an animal disease," Diouf told a news conference.

"We agree with the precautionary measures, but the strategy should focus on stopping avian influenza at the level of poultry and birds," he said.

"If we are able to eliminate or at least limit the number of birds that are infected, then we would limit the risk of transmission to human being and other consequences."

In Indonesia, the H5N1 virus has been found in about two-thirds of the country's 33 provinces.

At least 30 people have died of bird flu in Indonesia, the second highest toll of any country. More than half that number have died this year.

A case involving up to seven family members, six of whom have died, has raised alarm around the world because authorities cannot rule out human-to-human transmission.

The global death toll of 115 does not include the latest World Health Organisation confirmed cases in Indonesia.

While the death toll has climbed, the government has resisted mass culling of birds, citing the expense and impracticality in a country where keeping a few chickens or ducks in backyards is common.

Culling at selective farms and their immediate surroundings has been the preferred method.

"We need to strengthen veterinary services in Indonesia, provide them with protective equipment for handling infected birds and develop a compensation programme for those whose poultry are affected," Diouf said.

The organisation has provided $4 million and has been mobilising another $4 million to support Indonesia, he said.

H5N1 human cluster raises questions about genetics

Updated Fri. May. 19 2006 10:51 AM ET

Helen Branswell
Canadian Press

link

link

A large cluster of human cases of H5N1 avian flu in Indonesia is raising questions about whether genetic susceptibility explains why some people exposed to the dangerous virus become infected while many more do not.

Scientists have been puzzled by why H5N1 doesn't jump to humans from birds more often, given the vast numbers of exposures people have had to infected poultry in affected countries.

News that six members of one family have been confirmed to have contracted the virus (another likely had it but died without being tested) inevitably points suspicion to some genetic feature of this family's make-up that rendered its members more vulnerable than others in their village in the Karo district of North Sumatra.

"It makes perfect sense. It would not surprise us at all," said Dr. Richard Webby, an influenza virologist at St. Jude Children's Hospital in Memphis, Tenn.

"There's plenty of evidence, not necessarily in influenza, but there are other . . . viruses where there are certainly host factors that predispose someone to more severe disease."

The World Health Organization confirmed details of the cluster Thursday.

A 37-year-old woman from the village of Kubu Sembelang fell ill on April 27 and died on May 4. No samples were taken during her illness or before her burial and it's unlikely the cause of death will ever be confirmed.

Since then, six of her blood relatives have fallen ill - two sons, a brother, a sister, a nephew and a niece. All have tested positive for the virus and five have died. Just how the family contracted the virus is not yet clear.

Clusters of cases are worrisome as they could signal that the virus is transmitting from person to person. But people who live in close proximity often share experiences and exposures. That makes it difficult to interpret whether a cluster is simply a series of bird-to-human cases or something more.

The Indonesian family cluster is the largest seen to date, but a number of groupings of cases among family members have occurred, most recently in Turkey and Azerbaijan.

And a WHO scientist who was involved in the investigations of those clusters said the latter, at least, should serve as a warning for those who want to jump to conclusions about genetic susceptibility.

The emergence of seven cases - some members of a family, some neighbours - in the tiny settlement of Daikyand in April rang alarm bells. While the source of that outbreak hasn't been officially declared, investigators believe the victims were involved in defeathering swans - an illegal activity which survivors of the victims tried to hide from authorities.

If the theory is correct, it was likely exposure, not genetics, that led to that cluster, said Dr. Guenael Rodier, special adviser for communicable diseases to the regional director of the WHO's European office.

"Of course you can imagine that some human beings offer more binding opportunity for the virus than others," Rodier said from Copenhagen.

"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."

Trying to deconstruct family clusters looking for evidence of genetic susceptibility poses unique challenges for disease investigators.

"When you have clusters occur in families, sure, it's telling you something," said Dr. Keiji Fukuda, acting head of the global influenza program at the WHO's headquarters in Geneva.

"It's telling you that there is something different about that family as opposed to other people in the general community.

"But what it doesn't tell you again is whether there are shared exposures, shared conditions, shared behaviours, shared genetic backgrounds, shared local environment which is just different enough from their neighbours to make it so that they get infected as opposed to other people."

Even if scientists started to feel confident that genetic susceptibility may be playing a role, there is little that information can offer public health officials trying to quell outbreaks or lower the pandemic risk posed by the virus.

"When you're dealing with an urgent situation, you're really looking to find what you can change and make it a non-urgent situation," Fukuda said.

"And genetic background is just something that we can't modify."

It also doesn't necessarily say much about what the virus would be like if it mutated and became a pandemic strain, said Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

"We have to understand what is currently happening doesn't necessarily dictate the future," Osterholm said.

Osterholm said he worries people who are drawn to the genetic susceptibility theory may believe that if only a portion of the global population is vulnerable to the virus now, that will protect against it becoming a pandemic strain. But given that influenza viruses mutate constantly, this cannot be assumed to be a static situation, he said.

Bloomberg link

May 24 (Bloomberg) -- World Health Organization officials intensified their investigation of the spread of bird flu among seven Indonesian family members and may consider raising the alert level for a possible lethal pandemic.

Any evidence of the H5N1 avian influenza strain being passed from human-to-human in a chain of three or more people may prompt the WHO to convene a panel of experts and consider raising the pandemic alert level, Maria Cheng, a spokeswoman for the WHO, said yesterday in Geneva.

``There will be a lot of pressure from some circles'' to raise the level of alert, Michael Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy, said by telephone from New York. The concern is that ``other cases are being unrecognized.''

Cases involving sustained human transmission would suggest the virus has undergone genetic changes making it more contagious, according to the WHO. So far, studies of the Sumatran outbreak and genetic analyses of the virus don't indicate it has undergone major changes, Cheng said.

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 H5N1 cases confirmed by the WHO since late 2003 can be traced to direct contact with sick or dead birds.

A 10-year-old girl probably died yesterday of avian flu in Indonesia's West Java province, the Jakarta Post reported, citing Djatnika, a hospital official in Bandung, the provincial capital. The case is unrelated to the family cluster on Sumatra.

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 one-eighth, according to a report in February by the Lowy Institute and Australian National University.

Rupiah Slides

Indonesia's currency fell to a one-week low after the WHO statement. The rupiah declined 1 percent to 9,334 per dollar at 11:16 a.m. in Jakarta. Against the euro, the dollar strengthened to $1.2788 at 12:29 p.m. in Tokyo from $1.2815 in New York late yesterday.

An international team of experts joined local authorities last week on Sumatra to try to pinpoint how the people became infected with H5N1 in the past month.

The Indonesian Health Ministry and the WHO have intensified their investigation and response activities, the United Nations agency said. ``Priority is now being given to the search for additional cases of influenza-like illness in other family members, close contacts, and the general community,'' it said. More than 30 people are being monitored for symptoms.

Fever Surveillance

A temporary command post will coordinate fever surveillance in Kubu Sembelang, the village in North Sumatra's Karo District, where most of the family members lived, said Sari Setiogi, a WHO spokeswoman in Jakarta. Infectious disease training will be conducted at the local hospital, she said.

The investigation has so far found no evidence of a spread within the general community and no evidence that efficient human-to-human transmission has occurred, the WHO said.

``It appears that this virus has not gone outside this family cluster,'' said Peter Cordingley, a spokesman with the WHO in the Philippines capital, Manila. So far the virus ``has shown no signs of mutation.''

A 32-year-old man from Kubu Sembelang died of avian flu earlier this week, marking the seventh case in the family and the sixth person to die. His 10-year-old son died of H5N1 nine days earlier on May 13.

Thai Family

Health officials found strong evidence of direct human-to- human spread of H5N1 in Thailand in 2004, when it probably spread from an 11-year-old girl to her aunt and mother, killing the mother and daughter. People who had more casual contact with the girl didn't become infected.

Epidemiologist Osterholm said some health officials may call for the alert to be raised to level 4. The WHO's pandemic alert is at the third of six levels, indicating that a new flu virus subtype is causing disease in humans, though not yet spreading efficiently and sustainably among people.

``It that happens we're looking at a very bad situation,'' the WHO's Cordingley said. ``We have no idea how many people might die. We don't know how contagious it might be.''

To contact the reporters on this story:
Jason Gale in Singapore at j.gale@bloomberg.net;
John Lauerman in Boston at jlauerman@bloomberg.net.
Last Updated: May 24, 2006 00:42 EDT

WRAPUP 2-No sign of bird flu mutation in Indonesia case -WHO
Wednesday 24 May 2006, 4:51am EST

Reuters

(Recasts, adds market reaction)

By Diyan Jari

JAKARTA, May 24 (Reuters) - Limited human-to-human transmission of bird flu might have occurred in an Indonesian family but there is no evidence the virus has mutated to allow it to pass easily among people, the World Health Organisation said.

Fears of human-to-human transmission pushed down European shares and boosted demand for safe-haven bonds on Wednesday, lifting benchmark Bund futures to their highest in more than six weeks. The dollar rose against the yen.

Concern has been growing about the case in north Sumatra in which seven family members from a village died this month. The case is the largest family cluster known to date, the WHO has said.

The WHO and Indonesian health officials are baffled over the source of the infection but genetic sequencing has shown the H5N1 bird flu virus has not mutated, the U.N. agency said on its Web site (http://www.who.int) on Tuesday. Nor was there any sign of the virus spreading among other villagers.

"To date, the investigation has found no evidence of spread within the general community and no evidence that efficient human-to-human transmission has occurred, the WHO said.

"Sequencing of all eight gene segments found no evidence of genetic reassortment with human or pig influenza viruses and no evidence of significant mutations," the WHO statement read.

"The human viruses from this cluster are genetically similar to viruses isolated from poultry in North Sumatra during a previous outbreak."

Sick poultry have been the source of bird flu infections for the vast majority of human cases worldwide. The virus can also infect pigs.

Clusters are looked on with far more suspicion than isolated infections because they raise the possibility the virus might have mutated to transmit efficiently among humans.

That could spark a pandemic, killing millions of people.

Financial markets have become worried after the WHO said one of the family members, a 32-year-old father, died on Monday after caring for his ailing son, who also died.

The agency said such close contact was considered a possible source of infection.

WORRYING

"This is the most significant development so far in terms of public health," Peter Cordingley, spokesman for the West Pacific region of the WHO, told Reuters Television in the Philippine capital on Wednesday.

"We have never had a cluster as large as this. We have not had in the past what we have here, which is no explanation as to how these people became infected."

"We can't find sick animals in this community and that worries us," he added.

Bird flu has killed 124 people in ten countries since it re-emerged in Asia in 2003. It remains essentially a disease in birds and has spread to dozens of countries in wild birds and poultry.

Limited transmissions between people -- the result of very close and prolonged contact when the sick person is coughing and probably infectious -- are very likely to have occurred before in Hong Kong, Vietnam, Thailand and Indonesia.

Close contact also occurred in the Sumatran family, the WHO said, giving its first details of the case.

So far, investigators know that a woman, known as the initial case, appeared to have been the first to become ill at the end of April. She died in early May and was buried before samples could be taken from her body.

"Preliminary findings indicate that three of the confirmed cases spent the night of 29 April in a small room together with the initial case at a time when she was symptomatic and coughing frequently," the WHO Web statement on Tuesday reads.

"All confirmed cases in the cluster can be directly linked to close and prolonged exposure to a patient during a phase of severe illness. Although human-to-human transmission cannot be ruled out, the search for a possible alternative source of exposure is continuing," the WHO said.

Markets are also nervous about a suspected family cluster in Iran.

An Iranian medical official told Reuters on Monday that a 41-year-old man and his 26-year-old sister from the northwestern city of Kermanshah had tested positive for bird flu.

But Health Minister Kamran Lankarani denied this although international health officials are still investigating.

The two siblings were among five members of a family who became sick and the other three remain in the hospital.

Romania reduces avian flu quarantines in Bucharest

May 23, 2006 (CIDRAP News) – Romanian officials today lifted quarantines that had sealed off more than 14,000 people in Bucharest over worries sparked by two outbreaks of avian influenza in birds, but one small area remained closed, according to news agencies.

Although Romania has had no human cases of H5N1 avian flu, troops and police yesterday sealed more than 13,000 people in Bucharest's southern fourth district, according to Agence France-Presse (AFP). A smaller area on the northern outskirts of the capital had been closed off the night before, affecting more than 1,000 people, AFP reported.

Today the quarantine in the southern fourth district was reduced and the northern area was reopened. "We decided to isolate only five streets, or less than 500 people, so as not to distress the population," said Adrian Inimaroiu, the district mayor, as quoted by AFP.

Yesterday Inimaroiu had said the quarantine would last from a week to 21 days, during which "all institutions" would be closed, and 2,500 birds would be culled, the story said. But he reported today that only 230 birds in "high-risk streets" had been killed.

Inimaroiu was sharply criticized by Miorara Mantale, general administrator of Bucharest, over the quarantines. "There is no logical reason for putting 13,000 people under quarantine when only two farm yards have been contaminated," AFP quoted Mantale as saying. "If you had been a civil servant and not elected, you would have been fired."

The quarantines followed numerous outbreaks in poultry in recent days. According to AFP, Agriculture Minister Gheorge Flutur said today the virus had surfaced in 44 places, including the two in Bucharest, in the past 10 days.

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Deathcount to date: Zero. Nobody sick either. In fact, it's a nice, sunny day.

But hey, I'm pissin' my pants with terror at the prospect...;-)

"Death before being dishonored any more." - Col. Ted Westhusing

http://effectmeasure.blogspot.com/2006/05/what-to-expect-next-in-indonesia.html

Tuesday, May 30, 2006

What to expect next in Indonesia

What I think we can expect from Indonesia over the coming weeks is a fair amount of confusion. Sporadic cases of bird flu continue to be reported. WHO's latest update adds six to bring the Indonesian total to 48, of which 36 have been fatal. The wide publicity given the large cluster in Sumatra is likely to increase the index of suspicion that new cases of pneumonia, if there is a history of exposure to poultry -- common in Indonesia -- will be admitted to a bird flu isolation ward as a precautionary measure.

As we noted in an earlier post, there are a huge number of pneumonias every year in Indonesia -- 186,000 cases in the under five age group in West Java alone in 2005 -- many with exposure to poultry. If even a fraction of these is pegged a "suspect" case, the wards will fill up quickly with suspect bird flu cases. The result will be detection of some more genuine cases and more reports of crowded wards full of suspect cases, all possibly without any real change in the incidence of disease.

Add to this the chaos of a devastating earthquake, a government unable to cope at any level and a world peering in with trepidation and you have a recipe for -- a fair amount of confusion.

Unfortunately, expecting to be confused does not lessen confusion.

posted by Revere at 7:52 AM

Effect Measure sums up the latest thinking on bird flu genetics and mutation.