Effect Measure

China, Pakistan and what’s expected

China tries to close the door on a possible H2H while Pakistan opens the door to human bird flu cases on the Indian sub-continent. First China. Two recent cases, a fatal case of a 24 year old male followed after a period of some days by the infection of his father raised the issue whether the son passed the H5N1 infection to the father. No one wants this to be the case and the Chinese, who are hosting the summer Olympics in Beijing have a lot at stake. The spin on this, though, is incomprehensible:

China’s health authorities said here on Monday that no human-to-human transmission had been confirmed in the two human cases of bird flu and the means of transmission in these cases, involving two family members in the Nanjing area, remained unknown.

“The virus in the first case originated with poultry and has not mutated. It has no biological features for human-to-human transmission,” Mao Qun’an, spokesman of the Ministry of Health, said, citing laboratory results.

But Mao said there were several possibilities for transmission in the second human case, which involved the father of the man in first case.

“Neither of the three possibilities has been confirmed and in-depth investigation is still being conducted,” Mao said. (CXinhua News Agency)

Chinese authorities have said there was no contact with sick poultry in either case or any reported poultry outbreaks anywhere in the vicinity. The claim is being made that some kind of analysis (sequence?) of the son’s virus showed it was from poultry. Except they don’t know any poultry source and in fact we don’t know what makes the virus transmissible (or not). But if they can tell from looking at the virus, than why is the father’s case still under investigation? Why not just look at the virus? If they can tell the son got it from poultry, presumably they can tell if the father did, too. Spin.

Now, Pakistan. There have been infected poultry on the Indian subcontinent but never reported human cases. Now Pakison is not only reporting two cases and they are yet another family cluster (there have been almost three dozen so far):

For the first time in the history of Pakistan, Bird Flu influenza has been confirmed among human beings after two brothers died at a local hospital in Peshawar.

According to spokesman of Health Ministry, two brothers Muhammad Ilyas and Tariq working in a poultry farm in Mansera suffered flu, few days back that later turned to be critical in the form of Bird Flu influenza (H5N1).

They were admitted to a local hospital in Peshawar where on Monday they died. (Onlinenews via ProMed; see also comments at Flu Wiki Forum)

Both brothers worked on a chicken farm in Mansera, so it is more than conceivable they both both got it form a common poultry source, although it has not been reported there was any H5N1 outbreak on the farm. The news report says the diagnosis was on the basis of blood samples sent for “formal testing in Laboratory” but we aren’t aware of any confirmation of the diagnosis from a laboratory with expertise in this area. Maybe it will come.

It’s flu season again and avian influenza is influenza. Expect to see more cases in poultry, humans and who knows what else. That’s the expected part. The unexpected part is the thing that worries everyone. The unexpected part we are all expecting, that is. If you know what I mean.


  1. #1 Brad Jergens
    December 14, 2007

    Everybody on every flu board said the Pakistan outbreak was nothing bur a rumor. Avian Flu Talk was the only site to confront the rumor and to try to find the truth. I heard they all even mass emailed the WHO requesting answers! Of course it wasn’t a rumor after all. Maybe all of the emails to the WHO worked! At least somebody like AFT did something instead of just standing around.

    For the best up to date Pakistan discussion, I would always go to



  2. #2 revere
    December 14, 2007

    Brad: If by “rumor” you mean unconfirmed, then I noted that in the post. If by “nothing but a rumor” you mean false, time will tell. I received it from ProMed and they do not report things without some minimal vetting, so I, along with them, will await confirmation or not. Your comment about “everybody on every flu board” is false.

    One reason AFT doesn’t get the respect it alone seems to feel it deserves is that they are continually pimping for themselves as the best source. I would rely more on being an excellent, proven, reliable source rather than self-promotion if you want respect.

  3. #3 Joe Six Pack
    December 14, 2007

    I second that emotion revere.

  4. #4 paiwan
    December 14, 2007

    The latest metagenomics research in marine virus has depicted the virus’ role in marine ecosystem as the main regulator and contributor. Nature Reviews Microbiology 5, 801-812 (October 2007) | doi:10.1038/nrmicro1750
    Marine viruses – major players in the global ecosystem
    by Curtis A. Suttle1

    I can not speculate virus’ regulating role in the terrestrial ecosystem too much. But from evolution history, terrestrial ecosystem shall follow this pattern. If in the near future, the research data confirms this hypothesis, then the bird flu control needs new paradigm to deal with, for instance to revise production protocol in poultry, so that chicken’s immunity is in the right tract of evolution, therefore the virus does not need to destroy them. As to human beings, I do not know how to speculate. Perhaps, only to stress on keeping life style of sustaining full-loaded immunity.

    Do you think that virus also regulates public health administration just look at China as a living case?

  5. #5 bar
    December 14, 2007

    Revere: Most H2H seems to be “family” and by my count, genetically related family.

    I assume that the option that a limited set of genotypes are susceptible to some current strains of H5N1 has been excluded, but have not seen any reports detailing.

  6. #6 revere
    December 14, 2007

    bar: There is no convincing evidence that a genetic relationship is required. We’ve posted on this a couple of times (most recently here. Remember that in a family (where contact is closest) the only people not genetically related are the mother and father, so the preponderance of genetic links is not unexpected. It may be true that there is a genetic component but there is as yet no good evidence for it.

  7. #7 stu
    December 14, 2007

    Let’s say farmer X contracts H5N1 from poultry. He then is attended to by and sheds loads of virus to his immediate family, some of who then also are infected. Is this considered H2H transmission, if the virus hasn’t changed?

  8. #8 revere
    December 14, 2007

    stu: Yes, it is H2H. Period.

  9. #9 M. Randolph Kruger
    December 14, 2007

    They just reported Myanmar as having a case of bird flu….last month. We are finding out about it after she has recovered….What about the ones that didnt?

  10. #10 Grace RN
    December 14, 2007

    revere-given that there have been this many reports of family clusters of H5N1, would it be appropriate for WHO to elevate the pandemic level now to Four?

  11. #11 caia
    December 14, 2007

    I saw on Crofsblog that four, not two, Pakistani men may have had H5N1. The first survived; the two brothers who died reportedly had no known contact with sick birds.

    A third brother who lives in the United States but was visiting Manshera at the time also tested positive for bird flu, but survived and has since returned to the US, Akhtar told dpa.

    Uh… bad?

  12. #12 caia
    December 14, 2007

    Well, according to Scott McPherson, the U.S. brother was examined and quarantined upon his arrival in New Jersey until he was deemed H5N1-free.

    That’s a definite upside, but the apparent h2h2h cluster still ain’t good.

  13. #13 caia
    December 14, 2007

    * New York, not New Jersey.

  14. #14 revere
    December 14, 2007

    caia: I’ve written a post for tomorrow about some of these cases. According to The Post in Islamabad there were 3 cases, but there may have been 4 by other sources. As always, I prefer to wait for more information. There seems to be conflicting evidence about whether the brothers both worked on a poultry farm or not (which would certainly have been a common source) and at this point we don’t have confirmation of H5N1. So we’ll have to see. The conflicting reports about the other brother (was he infected at some point or not) underline the difficulty here. I’ll wait to see.

  15. #15 stu
    December 17, 2007

    “Let’s say farmer X contracts H5N1 from poultry. He then is attended to by and sheds loads of virus to his immediate family, some of who then also are infected. Is this considered H2H transmission, if the virus hasn’t changed?”

    Posted by: stu | December 14, 2007 2:11 PM

    “stu: Yes, it is H2H. Period.”

    Posted by: revere | December 14, 2007 2:15 PM

    Bear with me. So the same virus can be transmitted from avian to human, but then it cannot then be transmitted again to another person? Maybe I am not grasping this but it seems like this is bound to happen with any virus. If the people attending the patient don’t take any precautions then isn’t the odds of being infected about the same as the patient’s were in getting from poultry? Not being contrary, just wondering.

  16. #16 revere
    December 17, 2007

    stu: H2H means transmission from one human to another. If it goes beyond that it is H2H2H, etc. We don’t know what makes something easily transmissible but getting a virus from an animal does not mean you will pass it on to another. You need to shed the virus in a form and in a quantity and via a mode that allows that. This may be very difficult to do but under circumstances of very close contact possible but not likely to happen to another person again. If the chances of passing it to another are, say, one in twenty, it will happen but then not likely go beyond that second person. The outbreak will burn out. But it is still H2H in that instance.

  17. #17 stu
    December 17, 2007

    Keying on the last two sentences, so it is certainly possible to pass H5N1 on. Not very efficiently, but possible. I just don’t see the difference between poultry shedding virus and humans shedding virus. Neither mechanism is effective (yet) but apparently is enough to infect people at what looks like similar rates. To me anyway.

    Visit a “hot” wet market or a H5N1 hospital room, similar odds. Some get it, some don’t. There’s been so many reports of suspected clusters that I’m skeptical if they are anything more than probability at work.

  18. #18 revere
    December 17, 2007

    stu: birds may shed in different amounts and expose a person in different ways than another person. One human being may shed differently than another and the person they expose may or may not be susceptible (for whatever reasons). H2H transmissibility may be rare (and different than B2H) and either may burn out after one round.