Iran still says no bird flu

Iran rejects reports of human bird flu cases
27 May 2006 12:27:29 GMT
Source: Reuters
TEHRAN, May 27 (Reuters) - Iran's Health Ministry said on Saturday the country had no human cases of the deadly H5N1 bird flu virus, dismissing statements by a medical official and lawmaker that early tests showed a third person had died of it.

A senior medical official told Reuters on condition of anonymity that preliminary tests in the northwestern city of Kermanshah showed a 30-year-old man died on Wednesday morning from H5N1 bird flu.

He said this would be the third death after a 41-year-old man and his 26-year-old sister were also shown by preliminary tests to have died of bird flu in Kermanshah, which lies some 100 km (60 miles) from the Iraqi border.

The World Health Organisation said on Thursday it had asked Iran for details on the tests run on the two dead pneumonia patients that the government said were negative for H5N1.

Kermanshah's parliamentarian Jahanbakhsh Amini was quoted by the Etemad-e Melli newspaper saying: "Preliminary tests on three members of a family who died in a suspicious manner in Kermanshah were positive."

However, Amini told Reuters these samples were then sent to Tehran where laboratories reported they were negative.

The Health Ministry said no "credible" tests had delivered a positive result on H5N1.

"The Health Ministry denies any news of bird flu cases in Kermanshah," it said in a statement.

Poor Indonesia

Recent Developments in Indonesia




FROM NEWSDAY
By The Associated Press

May 27, 2006, 3:29 PM EDT

Developments in Indonesia on Saturday:

* A magnitude-6.2 earthquake flattens homes and hotels in central Indonesia as people sleep, killing more than 3,000 and injuring thousands more in the nation's worst disaster since the 2004 tsunami.

* Activity increases at Indonesia's Mount Merapi, one of the world's most active volcanos, following an earthquake about 50 miles away. Opinions are mixed among geologists over whether the earthquake could spark a large volcanic eruption.

* Indonesia confirms three more bird flu deaths, including the sixth member of a family in North Sumatra killed by the H5N1 strain of the virus. The deaths are part of a spike that has prompted the World Health Organization to place the maker of the anti-bird flu drug Tamiflu on alert for the first time after limited human-to-human transmission was suspected in the Sumatra family cluster.

* East Timor, which broke from Indonesian rule in 1999, descends further into chaos as rival gangs attack each other in the capital, and the prime minister says a coup is under way. In response, the United Nations orders families and all nonessential staff out of the country.

Hospital preparations

Stern: Hospital must prepare for pandemic

Health director advises doctors to plan now for the next pandemic flu
By JIM HALL


Date published: 5/27/2006


This week's headlines from Indonesia gave urgency to Dr. Donald R. Stern's message: Now is the time to begin preparations for a pandemic flu.

Stern, the director of the Rappahannock Area Health District, told doctors and nurses at Mary Washington Hospital yesterday that a severe and widespread flu outbreak is likely, though the timing is unknown.

Stern quoted another flu expert as saying: "The pandemic clock is ticking. We just don't know what time it is."

As Stern was speaking, several flu experts were in the Kubu Sembelang village of North Sumatra to investigate a cluster of six deaths from a single family there.

The family members died after contracting the H5N1 avian influenza virus, according to the World Health Organization. The latest death was a 32-year-old man who developed symptoms May 15 and died May 22.

All of the cases have been linked to close and prolonged exposure to a severely ill patient, according to the WHO. To date, the investigators have found no spread to the general community. They also have found no evidence that the virus has mutated to make it easier to spread from chickens to humans or from humans to humans.

"So far, the spread of H5N1 virus from person to person has been rare, inefficient and unsustained," according to the federal Centers for Disease Control and Prevention.

As of May 23, the WHO has recorded 218 cases of avian flu in humans, with 124 deaths. Stern refers to these as "incidental" cases, usually among people who have had contact with diseased chickens.

The disease occurs naturally in wild birds and can be deadly in domestic fowl. The disease was first identified in 1997 and continues to spread. Now it can be found in Asia, Europe and Africa.

But it is the possibility of a genetic shift in the virus and more efficient transmission from humans to other humans that concerns health officials, Stern said.

"There's a huge population that's being exposed to this virus," Stern said.

A "novel" virus for which the public has little immunity--like a mutated bird virus--could move swiftly around the globe and cause thousands of deaths, Stern said. Such pandemics occurred in 1918, 1936, 1957 and 1977.

"History tells us that we have these pandemics periodically," Stern said.

Stern spoke to hospital leaders recently about preparing for such an outbreak, and he speaks to elected officials next week.

His message: "How are we going to handle the demand for health support? We have some work to do."

Stern estimated that a "moderate" pandemic of the type that hit in 1958 would result in 78,000 illnesses in the Fredericksburg area. Over a three-month period, 700 people would need hospitalization, 100 would need intensive care and 50 would need the support of a ventilator.

"How many ventilators do we have in this hospital?" Stern asked the doctors.

When no one answered, he said, "Anybody know? Any pulmonary folks here? Anybody take a guess?"

Still there was silence.

"How can we plan for this if we don't even know how many ventilators we have on board?" he asked. "We need to know this."

http://fredericksburg.com/News/FLS/2006/052006/05272006/194552

No Mutation Seen in Indonesia

No sign of bird flu mutation in Indonesian family
*
*Poultry at an Indonesian market
Sophie Hebden
26 May 2006
Source: SciDev.Net

Early tests on an Indonesian family that is being investigated for possible person-to-person transmission of bird flu do not suggest the virus has changed significantly, says the World Health Organization.

The tests looked at the genetic make-up, or 'sequence', of the virus that infected the family members who fell ill first.

A spokesperson from the World Health Organization (WHO) told SciDev.Net that researchers are looking at sequences of the viruses found in the relatives who became ill later.

The family, from North Sumatra, has sparked interest among influenza experts because it is the largest family group known to be infected by the H5N1 virus so far. Six of seven family members who have died were confirmed to be infected with the virus, and an eighth relative is being treated in hospital.

Another unusual aspect of the case is that no one has been able to determine when or if the eight relatives came into contact with sick birds.

The uncertainty has led to investigations into the possibility that the virus could have been transmitted between them.

According to the WHO, "All confirmed cases in the cluster can be directly linked to close and prolonged exposure to a patient during a phase of severe illness."

The WHO spokesperson said no other villagers had shown any flu-like symptoms, although some have been quarantined.

She also said the WHO is investigating a second bird flu cluster in a brother and sister who died earlier this week in Bandung, West Java. A laboratory in Hong Kong is verifying that they were suffering from H5N1 infection.

Researchers at the Hong Kong laboratory are also continuing to sequence viral samples from the Sumatra cluster. Results are expected next week.

Possible cases of human-to-human transmission have been seen before, though never on this scale (see Bird flu deaths raise fears of human spread).

FROM THE JAKARTA POST, JAKARTA, BANDUNG

The ASEAN Foundation, one arm of the Association of Southeast Asian Nations, has said it is time to turn to technology for help.

The foundation proposes using information and communications technology (ICT), particularly short message service (SMS), to prevent further outbreaks of the disease.

The idea is based on the successful application of ICT in Thailand and Vietnam to stop new bird flu cases in both humans and animals at village level. The foundation is now applying ICT for the same purpose in Laos and Cambodia.

The foundation's executive director, Apichai Sunchindah, said Thailand and Vietnam had been successful in dealing with bird flu through the use of information technology.

In Thailand, he said, one million volunteers -- equipped with cellular phones or computers -- were deployed at village level. They filed their reports via e-mail or text message to a central terminal for the government to follow up.

"With this system, people are involved and the government can map out the spread of bird flu to take sufficient measures," Sunchindah said on the sidelines of an international symposium on ICT for social development in Jakarta on Tuesday.

While Indonesia is struggling to contain bird flu, there have been no reports of new cases in Thailand or Vietnam this year, winning them praise from international communities.

Professor Felix Librero from the University of the Philippines, who has conducted intensive research on the use of text messages to pass on information to fight bird flu, and managing director of Malaysia's Southbound Sdn. bhd. Chin Saik Yoon, both agreed the method would work in Indonesia.

There are about 60 million cell phone users in the country.

Expect the state to get Tamiflu to you?

Most states and cities lack adequate plans to dole out drugs and respirators
needed to combat a flu pandemic, leaving the nation with a critical gap in
preparedness, public health officials say.

The federal government has a stockpile of millions of doses of anti-flu
drugs and thousands of respirators, but health advocates fear the medicine
and equipment could languish in storage or on airport tarmacs during a
devastating outbreak.

"You can have all the Tamiflu and respirators in the world, but if you can't
get them to the people who need them, they're not much good," says Kim
Elliott of the non-profit Trust for America's Health.

The pandemic-related drugs, such as the anti-viral medicine Tamiflu, are
kept in the federal government's Strategic National Stockpile. The stockpile
is a huge cache of vaccines, antidotes and medical supplies that can be used
to respond to disease outbreaks, bioterrorism and other health emergencies.

Supplies are maintained by the federal Centers for Disease Control and
Prevention (CDC) and are stored in secret locations across the country. They
can be flown or driven within 12 hours to state distribution centers, but
from there, it's up to the states and cities to pick up the supplies and get
them to their residents.

As of December 2005, the government granted "green" status to only seven
states prepared to deliver supplies from the stockpile, according to
Elliott's group.

"It's something that, frankly, keeps us up at night," Elliott says.

The CDC, which is giving states $350 million to develop pandemic
preparedness plans, reviews state stockpile plans regularly and rates the
states on overall preparedness.

The government won't say which states have been granted green status. The
trust recently reported that 43 states and Washington, D.C., are either
unprepared or only partially prepared to deliver the stockpile. Six of those
were labeled "red," or the least prepared.

Asia is struggling with an outbreak of the H5N1 strain of bird flu. There's
no evidence the avian flu will mutate to become contagious between people -
a development that could launch a pandemic that would threaten millions -
but infected birds could show up in the USA in a matter of months.

Homeland Security Secretary Michael Chertoff says his department will review
preparedness plans. "I don't think we have any time to lose," he said. "This
is the kind of catastrophic thing that has to be on the front burner."

Georges Benjamin, director of the American Public Health Association, says
states need to conduct exercises to see whether the plans they develop will
actually work.

"It's a big logistical challenge," he says.

Donna Knutson, a CDC senior adviser on terrorism preparedness and emergency
response, says states should try to have workable plans in place within
three to four months.

"We've come a long way," she says, "but we also have a long way to go."

Source: USA Today

From Recombinomics

Here's something interesting about the genetics of what is going on in Indonesia. I am not sure what it means but:

Familial clusters in Indonesia have been common. Almost all have a 5-10 day gap between the index case and family member. Recently a seven member cluster in North Sumatra was described. H5N1 has been confirmed in all but the index case, and six of the seven have died, This cluster, the largest to date, has fueled concern about increased efficiency of human-to-human transmission. This cluster may be extended because one of the family members (10M) developed symptoms later than the other family member, and now the father of that fatal case has been hospitalized.

The growth in the number and size of the clusters has focused attention on the sequences of the H5N1 isolated from the patients. However, sequences from only one of the human H5N1 isolates has been released. It has a novel cleavage site, RESRRKKR, that has not been reported in any of the publicly available bird sequences from Indonesia or elsewhere.

These data suggest that the majority of the reported humans cases in Indonesia have not been linked to an avian sequence. Most of the sequences human isolates have been from West Java, including various locations in Jakarta and suburbs. Some of the avian sequence also are from West Java (see below)

The lack of a connection with bird H5N1 sequences and the increasing size and number of human clusters has raised pandemic concerns.

Seven Indonesian Bird Flu Cases Linked to Patients (Update1)

May 23 (Bloomberg) -- All seven people infected with bird flu in a cluster of Indonesian cases can be linked to other patients, according to disease trackers investigating possible human-to-human transmission of the H5N1 virus.

A team of international experts has been unable to find animals that might have infected the people, the World Health Organization said in a statement today. In one case, a 10-year- old boy who caught the virus from his aunt may have passed it to his father, the first time officials have seen evidence of a three-person chain of infection, an agency spokeswoman said. Six of the seven people have died.

Almost all of the 218 cases of H5N1 infections confirmed by the WHO since late 2003 can be traced to direct contact with sick or dead birds. Strong evidence of human-to-human transmission may prompt the global health agency to convene a panel of experts and consider raising the pandemic alert level, said Maria Cheng, an agency spokeswoman.

``Considering the evidence and the size of the cluster, it's a possibility,'' Cheng said in a telephone interview. ``It depends on what we're dealing with in Indonesia. It's an evolving situation.''

The 32-year-old father in the cluster of cases on the island of Sumatra was ``closely involved in caring for his son, and this contact is considered a possible source of infection,'' The WHO said in its statement. Three others, including the sole survivor in the group, spent a night in a ``small'' room with the boy's aunt, who later died and was buried before health officials could conduct tests for the H5N1 virus.

`Directly Linked'

``All confirmed cases in the cluster can be directly linked to close and prolonged exposure to a patient during a phase of severe illness,'' the WHO said.

While investigators have been unable to rule out human-to- human transmission in the Sumatran cluster, they continue to search for other explanations for how the infections arose, the WHO statement said.

Health experts are concerned that if H5N1 gains the ability to spread easily among people, it may set off a lethal global outbreak of flu. While some flu pandemics are relatively mild, the 1918 Spanish flu pandemic killed an estimated 50 million people worldwide.

So far, studies of the Sumatran outbreak and genetic analyses of the virus don't indicate the virus has undergone major changes, Cheng said. Scientists at WHO-affiliated labs in the U.S. and Hong Kong found no evidence that the Indonesian strain of H5N1 has gained genes from pigs or humans that might change its power or spreading ability, WHO said.

Mutations

``These viruses mutate all the time and it's difficult to know what the mutations mean,'' Cheng said.

Health officials earlier found strong evidence of direct human-to-human spread of H5N1 in Thailand in 2004. Scientists reported in the Jan. 27, 2005, issue of the New England Journal of Medicine that the H5N1 virus probably spread from an 11-year- old girl in Thailand to her aunt and mother, killing the mother and daughter. People who had more casual contact with the girl didn't become infected.

In the Sumatran cluster, close, direct contact with a severely ill person was also needed for spread, Cheng said. Preliminary findings from the investigation indicate that the woman who died, considered to be the initial case, was coughing frequently while the three others spent the night in the same room. One of the three, a second brother, is the sole survivor. The other two, her sons, died.

``It looks like the same behavior pattern'' of close contact and caretaking during illness with the bird flu virus, Cheng said. To raise the level of pandemic alert ``it would have to be transmissible from more casual contact.''

General Community

The Indonesian Ministry of Health and international scientists are continuing their investigation to trace the origins of the infections, the WHO said in its statement.

``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,'' the WHO said. ``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.''

To contact the reporter on this story:
John Lauerman in Boston at  jlauerman@bloomberg.net.

Last Updated: May 23, 2006 14:46 EDT

IRANIAN CLUSTER??? or Staph Pneumonia??

Tests on two dead Iranians show H5N1 bird flu
Tue May 23, 2006 8:13am ET170

TEHRAN (Reuters) - Tests in Iran on the bodies of a brother and sister who died after falling ill with pneumonia-like symptoms showed they had the deadly H5N1 strain of bird flu, an Iranian medical official said on Monday.

The two -- a 41-year-old man and 26-year-old woman -- were among five members of the same family who became sick after returning from a trip to the town of Marivan, close to their home in the northwestern city of Kermanshah.

The three surviving relatives were in hospital and one of them remained dangerously ill, the official, who spoke on condition of anonymity, told Reuters. It was not clear when the brother and sister died.

Samples have been sent to international laboratories for further tests, and if the initial results are confirmed, these would be the first human bird flu deaths in Iran.

Confirmation of H5N1 could deal a major blow to Iran's poultry industry. The Union of Chicken Meat Farmers says the industry employs 600,000 people directly but as many as 3 million people are dependent on it.

"They had all returned from a trip to the town of Marivan when they fell ill with symptoms of staphylococcal pneumonia," the official told Reuters, adding that the brother and sister had later tested positive for H5N1.

A third family member, aged 30, had slipped into a coma in hospital in Kermanshah, which is 100 km (60 miles) from the Iraqi border in the mountainous Kurdish territories of Iran.

The Islamic Republic first detected cases of bird flu inside the country in February, when the virus was found in wild swans.

All Iranian officials contacted by Reuters said they had been instructed not to speak to the media, adding that only the health minister was authorized to comment. The H5N1 virus remains mainly a virus of birds, but experts fear it could change into a form easily transmitted from person to person and sweep the world, killing millions within weeks or months.

The virus has killed 123 people since late 2003, most of them in Asia, according to the most recent figures from the World Health Organization.

Iran's neighbors Turkey, Iraq and Azerbaijan have all reported deaths from the virus in recent months.

So far, most human cases can be traced to direct or indirect contact with infected birds.

© Reuters 2006. All Rights Reserved.

Iran denies bird flu deaths
Posted: Tuesday, May 23, 2006

Geneva

Iran's health minister has denied that two siblings had died of bird flu, a day after a medical official said they had tested positive for the virus.

If bird flu were confirmed as the cause of death, the cases would be the first human deaths from the virus in Iran, which first detected it in birds in February. It has killed people in Turkey, Iraq and Azerbaijan.

'Fortunately, these two cases were negative for avian flu. There is no confirmed case until now,' Health Minister Kamran Lankarani said on the sidelines of the annual meeting of the World Health Organisation (WHO) in Geneva.

Yesterday, an Iranian medical official said the 41-year-old man and his 26-year-old sister from the northwestern city of Kermanshah had tested positive for the H5N1 strain of avian influenza that has killed 123 people around the world.

Iranian officials also said yesterday that they were sending samples for testing to international laboratories, but today the relevant parties had not received them.

In Cairo, the WHO's regional adviser for emerging diseases, Hassan Al Bushra, said the agency had been told the results in Iran were negative for bird flu and that his office had not received any samples from Iran for testing.

The two siblings were among five members of a family who became sick. Surviving relatives were in hospital and one was dangerously ill.

The confusion over the Iranian family comes days after the World Health Organisation confirmed several members of an Indonesian family who died earlier this month were infected with the H5N1 flu virus.

Problems with Indonesia cluster reporting

Indonesia's bird flu fight riddled with problems
Tue May 23, 2006 1:57am ET163

By Tan Ee Lyn

JAKARTA (Reuters) - Indonesian laboratory chief Abdul Adjid sent one of his staff to a village in Sumatra to collect animal samples this month after several members of a family fell sick with the H5N1 bird flu virus and died.

The staffer came back with blood and nasal swab samples of a few ducks but failed with the pigs because he could not get anywhere near them.

"He was alone. He couldn't handle the pigs. People there were unhappy with the situation so they did not help," said Adjid of Indonesia's Veterinary Research Institute.

Those few, short sentences reflect a litany of simple, but tremendous, problems Indonesia, the world's fourth most populous country, faces in its fight against the H5N1 virus.

There's a lack of trained personnel and equipment and many Indonesians are ignorant about the disease and suspicious of government workers as well as efforts to control the virus.

Add to this a massive geographical landscape of 17,000 islands that stretch 5,000 kilometers (3,100 miles) from east to west and it makes control of any infectious disease a nightmare.

"There is substantial room for more work to be done. We are ramping up our team here to work with the Agriculture Ministry to increase personnel in the field to deal with the problem of surveillance and response to cases when they are found," said Larry Allen of the UN's Food and Agriculture Organization.

Since its first known attack on Indonesian poultry in late 2003, the H5N1 virus has wreaked havoc in terms of human lives and losses to the poultry industry. At least 32 Indonesians have died of bird flu, the second highest total in any country so far. Some experts blame the crisis partly on Jakarta's policy against killing large numbers of fowl in infected areas.

Sick chickens are the main source for human infections worldwide and experts say the best way to prevent the virus spreading is to stamp out the disease in poultry.

But the cash-strapped government says mass culling is just too expensive and too hard to carry out in many areas of the country. Widespread culling would also meet resistance in a nation where millions keep a few birds in their yards.

For millions more, fowl are essential to their livelihoods.

While Thailand and Vietnam seem to have controlled the virus, H5N1 is believed to be endemic in almost all Indonesia's 33 provinces.

ANGRY VILLAGERS

The medical community was alarmed last week when the World Health Organization confirmed the virus killed at least five members of a Sumatran family within a week -- the largest known cluster of H5N1 human infections.

Such "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. Such a change could spark a pandemic that could kill millions.

The first victims in that cluster in Kubu Simbelang village died in early May, but three weeks on, authorities have not been able to trace the likely source. "We cannot conclusively confirm or rule out the possibility of human-to-human transmission," said I Nyoman Kandun of the Health Ministry's communicable disease control directorate.

Animal tests have been inconclusive. Although Adjid's laboratory detected H5 antibodies in pigs, chickens and ducks in a village a short distance from Kubu Simbelang, they have yet to test for the N1 component -- something they cannot do without reference materials from the WHO.

Nasal swab samples were free of live H5N1 virus, which means the animals were not infected at the time of sampling.

But samples that are perhaps most crucial in solving the mystery -- those of chickens and pigs in Kubu Simbelang -- are missing, because villagers refused to help Adjid's staff.

Pigs are susceptible to human and bird viruses and because in Asia they are often reared in close quarters with people, they are also seen as likely sources of infection.

The family cluster has wrecked the poultry industry in the wider Karo region in north Sumatra and villagers have turned on the government, accusing it of not providing enough help.

In a show of anger, about 100 Karo chicken traders tore apart live chickens with their bare hands on Monday and defiant villagers have pledged to hold a traditional feast that involves slaughtering pigs and poultry and cooking them in blood.

"They are disappointed that we have not been more responsive. They are not angry, just unfriendly. They are unfriendly to the people from the central government, the provincial government," said Sidharta Pinem, head of animal husbandry in Karo Regency.

(With additional reporting by Achmad Sukarsono and Diyan Jari)

© Reuters 2006. All Rights Reserved.

ROMANIAN QUARANTINE

1 000s quarantined in Bucharest
22/05/2006 22:54 - (SA)

Bucharest - About 13 000 people were quarantined in the Romanian capital Bucharest on Monday as troops and police sealed off streets in response to the city's second bird flu outbreak, officials said.

The mayor of the southern fourth district, Adrian Inimaroiu, said residents would be cut off and all businesses in the area would be closed during the quarantine period of up to three weeks.

The move came after the agriculture ministry earlier on Monday confirmed the presence of the H5 bird flu virus in dead chickens found in the neighbourhood, the latest of dozens of outbreaks of avian flu in Romania this spring.

"About 40 streets have been blocked" in the Luica quarter, Inimaroiu said, urging residents to stay calm.

He said the quarantine would last for a "period of a week to 21 days and all the institutions in this quarter will be closed".

"About 2 500 birds from this area will be slaughtered as rapidly as possible," the mayor said.

A neighbourhood on the northern outskirts of the capital was put under quarantine on Sunday evening with fences blocking a dozen streets and police preventing anyone from going in or out, except for medical emergencies.

from avianflutalk.com

INDONESIA CLUSTER COMMENTARY

Commentary

Growing H5N1 Transmission Chain in Indonesia Raises Concerns

Recombinomics Commentary
May 22, 2006

The growing H5N1 bird flu transmission in Medan, Indonesia has raised transmission and transparency concerns. The cluster has now grown to eight, and seven members of the cluster have died. H5N1 has been confirmed in all except the index case and the disease onset dates indicate there have been three generations of human-to-human (H2H2H) or possibly four generations (H2H2H2H).

The index case developed symptoms on April 27. There was a family barbeque on April 29 and other family members began showing symptoms in early May. This gap between the disease onset date of the index case and additional family members indicates human-to-human transmission (H2H). Seven family members developed symptoms, and six were confirmed to be H5N1 positive. However, the last member to develop symptoms died on May 13 (the index case died on May 4 followed by deaths on May 9, 10, 12, 13, 14). That family member was the nephew of the index case and may have been infected by other family members, which would represent H2H2H.

Today his father died and has been H5N1 confirmed, suggesting the transmission chain has grown to H2H2H2H, which would represent the longest H5N1 transmission chain to date.

The cluster was described in the WHO update of May 18. The update described the index case and seven family members who had symptoms, including the uncle who is still alive and the nephew who had tested negative. Although the disease onset date fro the index case was given, the update withheld the disease onset dates for the family members.

Moreover, the update failed to mention the father of the nephew who died on May 13. The uncle had symptoms, had been given Tamiflu, and had left the hospital. He refused further treatment and died. However, this travel into the community prior to his death raises concerns about additional transmissions. The WHO update indicate that there was no evidence of spread beyond the immediate family, but did not reveal the release of the uncle and potential spread. The status of additional family members with early symptoms remains unclear.

The spread of H5N1 across three or four generations of infections is cause for concern. Sequences of H5N1 from the patients has been said to contain no mutations, but there is no indications that the sequences will be released. Sequences from only one Indonesian patient has been released. The sequence was deposited on August 1, 2005, but was withheld from the public until March 26, 2006. It has a novel cleavage site, which is shared by most of the sequestered human sequences from Indonesia. At least one sequence has a wild type cleavage site, but it has not been released. The sequences in this cluster would significantly increase the number of H5N1 human sequences from Indonesia, and should be done as soon as accuracy of the sequences has been determined. The other H5N1 sequences at the private respiratory should be released immediately.

The withholding of disease onset dates and the status of the family member who died today reduces credibility and dictates release of the sequestered sequences.

Media Link

Map

Troublesome worries about Indonesia and avian flu spread

22 May, 2006
INDONESIA
Human-to-human bird flu transmission feared in Indonesia
Health Ministry cannot rule out this possibility. The country is unable to control the virus. In China the WHO fears that official figures might not indicate how widespread the virus actually is.

Jakarta (AsiaNews/Agencies) – Indonesia cannot rule human-to-human bird flu transmission, said I. Nyoman Kandun, director of the Health Ministry's Communicable Disease Control Centre after an epidemiological investigation was conducted into a family cluster of six fatal cases in Sumatra, the last one confirmed today. Meanwhile the World Health Organisation (WHO) has voiced deep concerns the viral outbreak might be more widespread in China than hitherto thought.

“We cannot confirm that (human-to-human transmission) has occurred but we cannot rule it out,” Kandun said today. “The good news is there is not yet any mutation”

The death toll due to the H5N1 virus has reached 32 in Indonesia, half reported this year. But unlike other countries, the disease has not been stopped in archipelago. For experts the bird flu might be even more widespread that officially reported since the there are no WHO lab in the country. Samples must instead be sent to Hong Kong or elsewhere for testing.

Emil Agustiono, a senior official at the National Commission on Bird Flu, said that the lack of coordination among and between government agencies and international partners such as the WHO and the Food Agricultural Organisation (FAO), partly contributed to the rapid spread of the H5N1 strain of virus across 27 of the country's 33 provinces.

“There was a tendency to work individually, but now we're starting to step up our internal communication,” he said.

Poor inter-agency communication has been a chronic problem. The Health and Agriculture Ministries have always announced the results of their investigations separately. For example, in Medan (Karo Regency), where the WHO confirmed a cluster of seven people, teams from the Health and Agriculture Ministries came and announced their own separate findings confusing the public.

“In the next several days, I will coordinate a visit to the Karo regency. This time we'll have a strong team, consisting of representatives of all the agencies, to find out the source of the virus and how it spread,” Mr Agustiono said, adding that he suspected organic fertilisers would likely turn out to be the source.

Still, there is much confusion. Last week, a test from the Agriculture Ministry's laboratory in Bogor contradicted Agriculture Minister Anton Apriyantono's statement that pigs in the Karo tested positive.

China. Beijing's ability to contain the spread of the virus in poultry remains low, according to the WHO. “We do not think that there has been enough emphasis on the animal surveillance side to do that in China,” said Dr. Henk Bekedam, the WHO’s top representative in that country.

“Somehow the [. . .] system in China is unable to detect the circulating H5N1 (virus).”

None of China's 18 confirmed human cases to date have occurred in areas where outbreaks in poultry were previously reported.

“The human cases are the proof that it [the virus]is still circulating, that there is still something, but again, we don't know the extent,” Bekedam said.

He suggested China could look to Thailand and Vietnam, nations which have not reported a human case so far this year.

Backyard farms are the most dangerous because of poor surveillance and greater human-to-animal contact.

Moreover, while farmers are compensated for birds that must be culled to stop the spread of the virus, the level paid, especially for more expensive birds like ducks and geese, is seen to be on the low side. Chinese farmers must also wait six months before restocking compared to three months in other countries.

“From a preventive perspective, that's fine,” Bekedam said of China's position. But “you're out of business,” he said of affected farmers. “And that's the part of compensation I think that needs to be looked into.”

“The [. . .] situation is not optimistic,” Vice Premier Hui Liangyu told a national meeting on the prevention and control of avian flu.

His warning came as the Agriculture Ministry reported Saturday that more than 300 wild migratory birds have died in the remote province of Qinghai.

The WHO opened its annual assembly today on a sad note. Its director-general, Lee Jong-wook, died in hospital today two days after emergency surgery for a blood clot on his brain. (PB)

Death Rates High

WHO's Lee will miss talks on pandemic plans
SINGAPORE (Bloomberg): Talks at the World Health Assembly this week aimed at galvanizing a global response to a threatened influenza pandemic may be hindered by the sudden illness of the World Health Organization's director-general, Lee Jong-wook.

Lee, 61, is recovering from surgery to remove a blood clot on his brain, the United Nations agency said Saturday in a statement. He will remain in the hospital for several days and miss the annual key policy-setting meeting in Geneva on May 22-27, to be attended by delegates from 192 countries, the WHO said.

Lee was scheduled to address the Assembly on Monday.

"Dr. Lee suddenly fell ill this afternoon while he was attending an official function," the WHO said in its statement.

"He was taken to hospital by ambulance. Examination by medical staff determined that he required surgery in order to remove a blood clot on his brain."

Strengthening pandemic-influenza preparedness and response is one of the assembly's top agenda items as health officials worry the lethal H5N1 strain of bird flu circulating in parts of Asia, Europe, the Middle East and Africa may mutate into a form that's easily spread among people.

The lack of a clear cause for H5N1 infections in as many as seven members of an Indonesian family this month is unnerving authorities who are attempting to rule out the possibility that the virus was transmitted from person to person.

Avian flu could spark a pandemic if it spreads easily among people. Humans have no natural immunity to it, making it likely that people who contract any pandemic flu based on that strain will become more seriously ill than when infected by seasonal flu.

Experts at WHO and elsewhere believe that the world is now closer to another flu pandemic than at any time since 1968, when the last of the previous century's three pandemics occurred.

While previous pandemics have killed no more than 2 percent to 3 percent of those infected, more than half those known to have contracted H5N1 influenza have died.

Fatalities from H5N1 in the first five months of this year have surpassed 2005 levels as the virus spread to animals in more than 30 countries on three continents. At least 123 of the 217 people known to be infected with avian flu worldwide have diedsince 2003, the WHO said on Friday.

Almost all human H5N1 cases have been linked to close contact with sick or dead birds, such as children playing with them or adults butchering them or taking off feathers, according to the WHO. Cooking meat and eggs properly kills the virus. (***)
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