It's been less than a week since the first reports out of Pakistan that cases of bird flu were appearing there. At the time we warned that the coming of flu season meant these kinds of reports were to be expected, but by the weekend concern increased as a family cluster appeared. As common in the early days of an outbreak news reports were contradictory and confusing. We elected to wait. By Sunday, some excellent reporting by Helen Branswell and diligent combing of the news by flusites allowed us to make a preliminary summary. We fully expected more surprises.
The biggest surprise so far is that there have been no more surprises. The summary from last Sunday seems to be pretty much the way things stand now: eight cases confirmed, one more probable (case couldn't be confirmed because it was buried before a specimen was taken). Counting the unconfirmed fatality, there were two deaths and the rest had mild or moderate disease. It still hasn't been determined if there was only bird to human transmission or also some human to human transmission (which seems quite likely). The problem seems to be that the cases with exposure to other cases may also have had poultry exposure.
WHO epidemiologist Keiji Fukuda (who is a genuine expert in these matters) sounded like he wanted it both ways:
"Right now it doesn't look like pure human to human transmission. It looks like the veterinarian, who was the index case, and a number of other suspect cases had poultry exposure," Fukuda told Reuters in an interview.
"It is definitely possible that we have a mixed scenario where we have poultry to human infection and possible human to human transmission within a family, which is not yet verified."
But human to human transmission "would not be particularly surprising or unprecedented," he added. (Reuters)
Translation: It's not human to human. But it might be. And if it is, it's not surprising and no big deal. This was close and prolonged contact, not casual contact. I happen to agree with this. But if so, why does WHO keep saying that almost all cases come from poultry? There are many instances where no sick poultry have been identified and if it's not particularly surprising or unprecedented that there could be human to human transmission, then why go to such lengths to knock down the possibility whenever it appears? Because then there would be increased pressure to raise the threat level?
I'm not saying they should or shouldn't raise the level. There are practical consequences to doing so and if they don't think the nature of the threat has increased I'm OK with that. But in order to be OK with it I also need to trust them, something I'd have a hard time doing with the Pakistani health ministry, whose spokesperson, Orya Maqbool Jan Abbasi said this:
But Abbasi and other health officials said there was no suggestion of human to human transmission.
"Absolutely not," said Health Secretary Khushnood Akhtar Lashari. "The WHO is looking into all the things but whatever we have at the moment there's nothing to suggest that, remotely." (REtuers via Gulftimes)
No suggestion? Not remotely? The facts are indeed highly suggestive and the health ministry doesn't help their own credibility by this kind of straight out lying.
In any event, this story isn't over yet. A WHO team arrived in Peshawar on Tuesday to review hospital records and do case finding. A second team from the US NAMRU3 lab in Cairo was scheduled to arrive today to do more testing of specimens. The AP described this as confirmation of early tests, so it is not clear to us if the eight cases WHO has reported have been confirmed by a WHO reference lab as yet.
At this point the picture we and others painted last weekend still seems to be what happened. A cluster of four brothers, then two cousins of the family and three other cull workers elsewhere, two related. Early reports of an infected but asymptomatic health care worker have not been confirmed. The case fatality ratio for the Pakistani cases is just over 20%, lower than elsewhere but not so low as to be an outlier.
Bird flu is still out there in millions of birds and is making its way into some humans, rarely, but on a regular basis. Maybe this will continue to be the pattern.
And maybe not.
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Hopefully this is not off topic but related to the disease onset. In the five person family cluster reported this morning in Indonesia the various flu tracking site the translations of local news reports frquently say things along the lines of (cleaned up grammar) 'the chickens died yesterday' family members are symptomatic and transported this day. It makes it appears that the chickens died yesterday and everyone is sick today. Yet the consensus line in flubogia seems to be that there is a five - ten day incubation period. Still I frequently see translated news reports to effect that animals died yesterday and today folks are sick. Any explanation come to mind?
Perhaps the chickens are infectious previous to showing symptoms or before the onset of death.
carl: I think it is difficult to make sense out of things that have passed through three or four communication channels (event to someone else to reporter and/or editor to machine translator to flu site to us and we pass it on to others). That's one of several reasons I usually wait to see how things sort out. In the Pakistan case there was so much interest and speculation I didn't wait as long as I usually do, but the main facts seem to be holding up. Now that the index of suspicion and anxiety and distrust in authority is high, we will likely see a lot of reports. Because many infections trigger the innate immune sytem initially they all look alike initiailly: i.e., "flu like" symptoms.
In the Indonesian case there is talk of the AF cases actually consuming a duck or a chicket that came down with the flu. Which may or may not serious consequences transmission-wise.
Bird flu is still out there in millions of birds and is making its way into some humans, rarely, but on a regular basis. Maybe this will continue to be the pattern.
And maybe not.
Time will tell. I know an epidemiologist who concurs with you: the best surprise is no surprise, but she thinks there are probably more in store!
Dave Briggs :~)
In regard to Pakistan, why is WHO not releasing information regarding the age, gender, disease onset dates, hospital admission dates, dates of death, and the relationship between the confirmed bird flu cases?
The transmission chain has been the longest ever observed, and has lasted for six weeks. Therefore, it is necessary for WHO to release this information, because when there is a lack of transparency, it may be assumed by some the situation is very serious, but concealed.
If WHO destroys its credibility, what agency will replace it? The answer is none. And since governments are obviously not to be trusted; just notice the lies of government representatives in Pakistan; then the result will be a blackout of reliable information from human bird flu centers of infection in various coutries.
If it becomes impossible to obtain reliable information,
how will government agents know whether or not there is an increasing danger of a pandemic? How will public health agencies prepare? The answer is: they will not.
Herman wrote:
Because none of these cases have been confirmed by a WHO reference lab, which is the gold standard?
And because chances are they are still trying to pin down these dates. I'm no epidemiologist but I do have a fair amount of clinical experience taking histories. Do you have an idea how hard it is to get the correct sequence of events from even one LIVE, calm and coherent patient speaking the same language as you, telling you his/her symptoms firsthand? We are talking about layers of third and fourth parties, translators, bureaucracies, inadequate records, confusing names, in one of the most inhospitable parts of the world, where trust in outsiders is scant on the ground at the best of times.
Hint: look up Peshawar and North West Frontier Province. It is on the border with Afghanistan, the majority of the population being Pashtuns, original supporters of the Taliban. And where the 'war on terror' is an ongoing part of the landscape.
We don't know what the transmission mechanism is/was, let alone whether and how the chain went, and how long it lasted. I'm with revere in that this looks like a chain of transmission, but nothing is certain unless and until it is.
Just saying.
Driving home just now, I caught a brief squib report on NPR which said that WHO now considers the Pakistani cluster to have been genuine H2H.
Followed by the usual bromides. It's rare, everything is under control, trust the authorities, normal service will be restored promptly, normal service will be restored promptly, normal service will be... (awrk!)
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