The big newswires and health agencies are relatively quiet, but word keeps leaking out of Egypt that there are a lot of suspect bird flu cases:
CAIRO: Hospitals nationwide reportedly quarantined more human cases suspected of being infected with the H5N1 bird flu virus.According to Al-Masry Al-Youm newspaper, Damietta -- where the latest Bird Flu victim Hanem Atwa Ibrahim, 50, died late on Monday Dec. 31 in a Cairo hospital -- hosts the largest number of cases with five people suspected of carrying the virus, while the Upper Egyptian city of Qena came next, with two cases, followed by El-Beheira with one case. (Egypt Daily Star)
This has been noticed on the Flu Boards (see, for example, here and here) and is the source of understandable anxiety. It is not clear the extent to which the current public awareness campaign is effective in altering behavior but the publicity has also heightened anxiety in the Egyptian public and raised the diagnostic index of suspicion. All of this is appropriate, even though it will also create many new "suspect" caes. However I think there is one element that has been missing in the discussion.
Any kind of influenza infection in humans is potentially serious and life threatening. That's true in the US, where the estimated excess mortality exceeds 35,000 deaths a year, or in Egypt. It is flu season and people will be dying of this nasty virus on a daily basis. Thus a sudden increase in serious and fatal respiratory infections is not evidence H5N1 has run amok. But because there is a lot of flu around, it doesn't mean that finding most or all cases are negative means nothing is happening, either.
Let's do some quick back of the envelope calculations. Egypt's population is about a fifth of the US population, so on that basis alone we might expect 7000 excess deaths from influenza, mostly compressed into a six month flu season. These, of course, are only a fraction of the influenza cases. In the US the case fatality ratio for seasonal influenza is about 0.1%. Let's say it is five times higher in Egypt, 0.5%. That means the number of flu cases is 200 times more, or 1.4 million. Let's say only 20% of these are really sick and are seen by a health care worker. That's still almost 300,000 or close to 50,000 a month coming to medical attention if spread out evenly in the 6 month period (lack of uniformity would of course make some periods look much worse). If we assume that in the same month there are ten clusters of H5N1 of 25 patients each, the probability of a suspect case of influenza being H5N1 is only about 0.5%. There are also a bunch of other viruses that look like influenza, so these would lower the probability even more.
What does this mean? First it means that even if something pretty bad is happening, almost all suspect cases will be negative. Second, that there is so much influenza-like illness at this time of year that there is a real danger true clusters can get lost in the noise. Third, this fact notwithstanding, we shouldn't mistake the noise for a true signal. Just because there is a lot of noise doesn't mean it is hiding a true signal. So far it hasn't been, at least judging from the lack of a prairie fire spread of H5N1 cases anywhere, including Egypt.
The only solution to this knotty problem is to continue intensive surveillance for H5N1 in areas, like Egypt, where there is endemic infection in poultry and other birds. That's why the large number of "suspect cases" is a good thing, not a bad one. Suspicion means there is a greater chance of finding any H5N1 needle that might be hiding in the huge influenza-like-illness haystack.
If there is anything reassuring about this crude analysis it is that a large number of suspect cases doesn't mean something bad is happening. The worrying part is that a lot of negative suspect cases doesn't mean that something bad isn't happening.
This is where we separate the optimists from the pessimists. Meanwhile the realists will be working hard to establish an infrastructure that can make accurate diagnoses of serious pneumonias of unexplained origin. We should be encouraging them and helping them to do it better and faster. We can still look over their shoulders without getting in their way.
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Thank you Reveres in adressing this issue on Sunday with such eloquency and pertinence.
As you say we must keep things in perspectives and in their context.
Snowy
http://www.dailystaregypt.com/article.aspx?ArticleID=11159
This popped up this afternoon on the search. Other than the four cases in a week and the previous ones, nothing conclusive. There is a map at of all the cases. Some are updates on the same cases but as Snowy said, there are a crapload of somethings going on over there. About 51? The map shows their symptoms and even if 1/2 of them are BF we suddenly got a really big problem. Even if its another four its a big problem. These people live and die by their poultry as a food source. The Egyptians cant afford to cull the birds and pay the owners. So its like the honor system... dont eat a dead or dying one. Good luck on enforcement.
http://maps.google.com/maps/ms?hl=en&gl=us&ie=UTF8&msa=0&msid=106484775…
Revere, take a look at the map too plz. Look at the roads that are directly adjacent to the suggested cases? Someone is hauling bug laden birds or a reservoir of some kind around? Or is it coincidence?
What Snowy meant to say is "thanks for posting a link here and pumping our forum." That's probably the main purpose for the suspected-cases hoax to begin with. Or maybe he is just happy about the new excuse of having "better surveillance" to help bail Niman and group out of this.
Niman writes irresponsible commentaries and I'm sure everybody will continue to ignore it. Although he's not off the hook that easy in my book.
If we wouldn't have been telling people for a week now that none of this is true, I could only imagine what would be going on right now.
Albert, Snowy, etc.: I would appreciate it if people would keep the internecine flu board wars off EM. There is nothing to be gained by it here. If you guys -- all of you -- want to do that on your own sites that's your privilege. Henry has his own site, too, and he can use it as he sees fit. We write what we write independently. You don't have to like it and you don't have to read it. But please don't leave your garbage on our doorstep.
M. Randolf Kruger: Revere, take a look at the map too plz. Look at the roads that are directly adjacent to the suggested cases? Someone is hauling bug laden birds or a reservoir of some kind around? Or is it coincidence?
Keep in mind that Dr. Niman has mapped these suspected cases primarily by governorate (province) only -- not by villages/towns. Thus, this map doesn't give a good indication of whether or not these suspected cases are near roads or rivers or canals or whatever.
revere: Third, this fact notwithstanding, we shouldn't mistake the noise for a true signal. Just because there is a lot of noise doesn't mean it is hiding a true signal.
Quite so. As I said elsewhere, when the H5N1 outbreaks in Egypt first happened in March 2006, Egypt went from 0 to well over 150 suspected cases in just under two weeks. Granted several H5N1 cases were discovered around that time, but it was not the start of an H5N1 pandemic.
I have a feeling that we're seeing two things at the moment: 1) more people seeking out medical treatment 'cause they have flu-like symptoms and they've just heard about the 4 recent deaths -- I know I'd be nervous! (maybe greater vigilance on the part of medical folks, too?); and 2) increased reporting by the press because suddenly bird flu is news again.
Still, working under the assumption of "you never know", I think it's good to pay attention to these situations -- 'cause, well, you never know...!
Reveres, maybe you all should step out of the flu watching arena and stop pumping out stories on a daily bases if you can't handle the comments that go with it. Also, what you call "garbage" is what we refer to as the "truth".
I suppose since you all are apart of the so-called flublogia, this really only had one ending either way.
Take care all,
A
H5N1 avian flu: Spread by drinking water
There is a widespread link between avian flu and water, e.g. in Egypt to the Nile delta or Indonesia to residential districts of less prosperous humans with backyard flocks and without central water supply as in Vietnam: http://www.cdc.gov/ncidod/EID/vol12no12/06-0829.htm. See also the WHO webside: http://www.who.int/water_sanitation_health/emerging/h5n1background.pdf and http://www.umwelt-medizin-gesellschaft.de/ abstract in English �Influenza: Initial introduction of influenza viruses to the population via abiotic water supply versus biotic human viral respirated droplet shedding� and http://www.thelancet.com/journals/laninf/article/PIIS1473309907700294/a… �Transmission of influenza A in human beings�.
Avian flu infections may increase in consequence to increase of virus circulation. Transmission of avian flu by direct contact to infected poultry is an unproved assumption from the WHO. Infected poultry can everywhere contaminate the drinking water. All humans have contact to drinking water. Special in cases of decentral water supplies this pathway can explain small cluster in households. In hot climates/tropics the flood-related influenza is typical after extreme weather and natural after floods. Virulence of Influenza virus depends on temperature and time. If young and fresh H5N1 contaminated water from low local wells, cisterns, tanks, rain barrels or rice fields is used for water supply water temperature for infection may be higher (24�C: virulence of influenza viruses 2 days) as in temperate climates with older water from central water supplies (7�C: virulence of influenza viruses 14 days).
Human to human and contact transmission of influenza occur - but are overvalued immense. In the course of influenza epidemics in Germany, recognized cluster are rare, accounting for just 9 percent of cases in the 2005 season. In temperate climates the lethal H5N1 virus will be transferred to humans via cold drinking water, as with the birds in February and March 2006, strong seasonal at the time when drinking water has its temperature minimum.
Recent research must cause concern: So far the virus has had to reach the bronchi and the lungs to infect humans. Now it infects the upper respiratory system (the mucous membranes of the throat such as through drinking, and the mucous membranes of the nose and probably also the conjunctival of the eyes as well as the eardrum, such as through showering). In a few cases (Vietnam, Thailand) the stomach and intestines were stricken by the H5N1 virus but not the bronchi and the lungs. The virus might been orally taken, such as through drinking contaminated water.
The performance to eliminate viruses from the drinking water processing plants in Germany regularly does not meet the requirements of the WHO and the USA/USEPA. Conventional disinfection procedures are poor, because microorganisms in the water are not in suspension, but embedded in particles. Even ground water used for drinking water is not free from viruses.
In temperate climates strong seasonal waterborne infections like the norovirus, rotavirus, salmonella, campylobacter and - differing from the usual dogma - influenza are mainly triggered by drinking water, dependent on the water's temperature (in Germany it is at a minimum in February and March and at a maximum in August). There is no evidence that influenza primarily is transmitted by saliva droplets. In temperate climates the strong interdependence between influenza infections and environmental temperatures can't be explained by the primary biotic transmission by saliva droplets from human to human at temperatures of 37.5�C. There must be an abiotic vehicle like cold drinking water. There is no other appropriate abiotic vehicle. In Germany about 98 percent of inhabitants have a central public water supply with older and better protected water. Therefore, in Germany cold water is decisive to the virulence of viruses.
In hot climates and the tropics flood-related influenza is typical after extreme weather and natural after floods. The virulence of the influenza virus depends on temperature and time. If young and fresh H5N1 contaminated water from low local wells, cisterns, tanks, rain barrels or rice fields is used for water supply the water temperature for infection may be higher (at 24�C the virulence of influenza viruses amount to 2 days) as in temperate climates (for �older� water from central water supplies cold water is decisive to virulence of viruses: at 7�C the virulence of influenza viruses amount to 14 days).
Dipl.-Ing. Wilfried Soddemann - Free science journalist - soddemann-aachen@t-online.de - http://www.dugi-ev.de/information.html - Epidemiological Analysis: http://www.dugi-ev.de/TW_INFEKTIONEN_H5N1_20071019.pdf
The MIT report that it's 2,6 not 2,3 that counts when applied to Egypt means H5N1 is transforming at the same rate as last year or faster, in humans. If the same rate, that in and of itself will be interesting. If it's a faster rate, as we're seeing more bird clusters, then the sequence info will reveal "where we are", and will also reveal another insight into whether this is recombination, reassortment or point mutation. It's one of these.
I've voted for the predictable one. If it isn't predictable, well, we will cross that bridge when it's in front of us.
What I've despised for now 5 years is the failure to keep kicking the tires to decide on how 2,3 changes into 2,6...for a myriad of reasons, some of which now are finally in the dustbin.
Hey I was particularly cool and I was impressed by the umbrella shaped virus particles. I got the idea about how it worked from the graphics that were put out a while back with the gnarly thing that looked like a piece of pollen penetrating a cell. It was put out as a penetration originally. It sounds like a molding to a form and then penetration to me now.
But here are some questions. First how do you determine its umbrella shaped? Electron microscope?
Second, know that we know this does it mean that it we can make specific blockers to the specific receptors or do we just know better how it works?
Lastly, these people that have gotten sick so far and died. Did they have MORE of these specific receptors in vulnerable parts of the body and it allowed a mass invasion? Or is it the one size fits all? You get it you get infected and either die or get terribly sick. Luck of the draw?
Hi Ray, where in Hell have you been?
Welcome to the Internet Bird community. 15% of the population in some areas read blogs and personal, not professional commentary on issues. Sometimes, some of us are researchers, etc. and are active in the big picture. I was intrigued by the posts that kept coming up on the searches and were beginning to dominate some of the engines. It is either a monologue or a dialog. In the professional community, publishing articles, and peer review we have a dialog. It is like a Karaoke singer putting up a song and saying just for fun. We all read a lot of articles and sites and when you come up a lot, and its a blog not a professional research site, well what to say.. the right to comment.
Good summary Revere. I am amazed actually, that given the background "noise" of winter regular flu cases that become serious, even in places like Egypt, that we can discriminate H5N1 from other types. As you put it, how fine is our discrimination? Not very good if the initial sympoms are not severe (go home; take two aspirin).
Randy: I have read through the article at least once. It is quite complicated. The topology of the umbrella versus the cone comes from calculations on bond angles and torsions. I hope to post on this paper soon but there is a lot of explaining to do so writing the post(s) will not be easy.
Thx Revere.
Medclinician:
I really hate people treat public blog like Karaoke, they should do it at home............the right to comment? .......Can not be lenient, disdain that!
Paiwan - for all intensive purposes I spent my waking hours at our lab. We are health professionals, and there are some serious medical and journal quality posting material here. One should not joke, but President Bush on the campaign trail to our current location in person began his speech with a joke. So, in our exchanges on highly technical and medical topics, it easy to slip into medical jargon where the laymen, who I think a fair share read here, might be a little overwhelmed. There is a desire to simplify, not be unprofessional.I actually apologize, which is a first on the net, for allowing 2 hours of sleep and long hours make me realize, I am among many professionals, as myself, in research and medicine. I look forward to a lot more listening than posting. MC
MC: I one time read about the topic of virus origin, I remember the author is Eugene Koonin and peer reviewed by P. Forterre, etc. Great example of comments. Researchers are aloneliness( not loneliness), whereas the blog is for open forum, I guess, it encompasses the educational and informative functions. Different audiences.
What I meant was sincerity. I observe that Revere has prevented several posters of pretense, sort of fake participation. The area for deeper dialogues perhaps needs some moderation skills in asking deeper questions. Leaving with good questions are beneficial for everyone. The confusion is the judge (moderator) and heavy-weighted player could be confusing if there is no boundary.
Hello, all of you,
I am a french layman (journalist though). I see there are a few specialists among yo. . I read that RNA results about avian flu analysis take typically 2 days and perhaps 2 or 3 other day for reasonable public release.In fact, some people were hospitalized many days ago.
I ask you a question, please :why don't we know, yet, more results, negative or positive? Is there a technical reason, or is there any witholding?
Sorry for bothering. Have a good night
dominique: You will probably get different opinions about this. It dpends on what kind of information you want, from whom and about what. Some is available quickly, some not so quickly and some depends on whether the member state allows it to be released or not. Do you mean info on whether someone is infected? Where?
Thank you for answering Sir,
I get indid many opinions about it. But,I will be direct, I am gathering informations in the way to understand the situation and its grade of gravity.
For me:
First solution, the many, and increasing, suspected cases are seasonal flu (we must hope that),
Otherwise it could be the premice of a pandemic crisis(even with a Tamiflu blanket effect delaying positive results). Then the things could go very quickly and we must know that.
Could it be? Am I right or too pessimist?
Do I ask for the good questions?
All that is my personal questioning. My purpose is not to scare people with alarmist news, nor to hide any grievous thing.
thanks again for your patience
I realize I didn't answer your question "where?".
I mean persons infected by avian flu in Egypt.
Indid the real ratio infected/suspected would be interesting.
Furthermore the human infection zones seem, at least sometimes, to correspond with poultry infection areas.
dominique: I think the post attached to this comment thread is the best I can do. We'll have to wait and see.
Dominique-I am accused by some of being a fear monger here but let me put it into perspective. If it really is coming there wont be any question when it does. You could look up "herald wave" here:
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7581-47W60JD-…
http://aje.oxfordjournals.org/cgi/content/abstract/116/4/589
There was more than anecdotal evidence that H1N1 floated around China for years before it made its presence known to the rest of the world in 1918. Indeed there were a lot of arrows point into France but it didnt start there. It may have given us the "herald wave" warnings because of the high incidence of "Le Grippe" from about 1915 on. High incidence of flu with no description other than high fever, congestion, pneumonia followed by death. But it was the same for ordinary flu too so what was 1918 herald and what was full blown H1N1? No one knows other than in 1895 there was an outbreak of what had of have been flu in Guangdong Valley. Only noted in the mandarins notes and missionary diaries apparently it was pretty bad. How bad? I found that over 1000 had died of what was flu in one entry in a month, but was it H1N1? No one will ever know and no way to determine it either.
Are we seeing herald waves or puttering of H5N1 along the way? I am not a doctor but as with so many we have the gut feeling that something is up. With a so far 83% case fatality rate regardless of whether its up or not, a box load of people have already died and the numbers keep increasing. If it were going away it would have started downward.
The bug is increasing its geographical reach, more and more cases are being reported, clustering in familial situations and healthcare workers are becoming part of the infected. All of those are pandemic criteria but it isnt a pandemic until the DG of the WHO says it is.
That if you have been here for a while makes me nervous. She makes the call late and many more people will not have desirable outcomes. She makes the call too early and she will be castigated out of office and its a political office. So IMO, if they make the call it will be early for some, just right for others and absolutely too late for many. Its the many that bother me because it could break out anywhere of course but more likely it will be in a poor area such as SE Asia or Indonesia. By the time their surveillance picks it up, makes the determination that its out and coming, and notifies appropriately the WHO it will be too late for those people in that area.
Its all about the resources though Dominique. If you have few resources and this comes and you have to operate in a BF zone the outcome will likely not be good. Resources would be personal in nature such as food, water, medicines, bailout position to go to, power, heat those kinds of things. We could spend hundreds of billions of dollars to beef up the infrastructure in health care but very likely it wouldnt percentage wise raise the outcomes level much if any. Michael Pezzulli "Pezz" who is a contributor here held a tabletop exercise in his town where he is a councilman and they lasted in a 5% event 11 days before they had to say they lost control of the situation. If it were 30% he felt it wouldnt be much more than 3 days because those resources fell apart so quickly. So you have to assume you will be on your own. How long? How bad? Many waves? That will require a crystal ball of immense proportions.
No police, fire or governmental services.
We all are waiting for something descriptive and informational to come out of Egypt, but it hasnt other than to say they have isolated 10 additional people. Isolation is different from quarantine. One woman bailed out on them yesterday their time after a confirmation of H5N1. She roams the streets now for all intents and purposes and could be or might be infecting people as she goes. If it were truly pandemic flu then it would be spreading rapidly now... I think its more like epidemic flu and H5N1 flu at this juncture. It just hasnt figured out how to get us yet. But thats the difference. If it were wouldnt be writing about this right now, we would be disseminating information on how to survive it.
Be vigilant. H5N1, H7, H3, etc are all circulating so as they say its inevitable.
Separating facts from fiction. On one hand we are receiving official (although dated) confirmed cases in Egypt. Then we are seeing long lists with many names and claims of hundreds of cases. Clash. Question. Where are these lists coming from when we can barely get official numbers up to a dozen cases? Posted one article, Egyptian news on about 19 deaths or so dated 12/31/07. This was days before the very formal release of 2 deaths by our own mainstream in the U.S. H5N1, as most geneticists and epidemiologists will tell you, is a poor spreader. It is far more likely we will have an HxNx virus, just as we went from H1N1, which most are immune to now entirely, to something a little more creative. H5N1 is a spot hitter with some extremely limited human to human transmission. Referring to CDC archives you will find perhaps 3 or a few more cases strongly suggesting human to human transmission. The most relevant question is why viruses like Avian and SARS get so much focus, when we have three current Pandemics, TB, Dengue Fever, and Malaria in full active mode. Look at the figures for Dengue Fever globally. The infections numbers are huge compared to Avian We get a few hundred even people in a country with Avian, and in Egypt that may be much exaggerated, with massive cases of other diseases in tropical countries Perhaps, as i the recent Ebola outbreak in Uganda (still another hotly debated topic) It when we start getting spurts of 100% CFR in humans that eyebrows go up. I have posted all over concerning the binding of MRSA and VRSA in amoeba cysts in hospitals making them airborne and dead silence. Does it spiral down to people don't die in large numbers. In the case of Dengue Fever and its very hemorrhagic sub-type which is pretty severe, it is as if the greatest health risks in that exist are being pushed aside to focus on a virus which up until now, is pretty lethal to poultry, but over a decade has not spread to humans in significant numbers. Is Avian popular as far as a news items versus its actual danger to us as potential Pandemic producer? It probably - H5N1 - will not be the one (IMHO)
Medclinician: We've been blogging this (and other issues) for over three years, so we are aware of the data. I am an epidemiologist. Our interest in bird flu is as a way to talk about public health. There are many more diseases "out there" that are of high importance. Pandemic flu is a convenient way to raise issues and an interesting lens to look at them through. We don't say it is the only problem or even the most important. Having said that, it has the potential to become extremely important as well. But you will see us talk about others, including TB. Stick with us or have a stroll through the archives or use the categories.
I haven't seen any comment on this post about the issue of false negative testing. Apparently, they are frequently seeing multiple negative H5N1 tests--with apparent symptoms of AI--with eventual positive results. Any comment? Revere, should the issue of false negative tests be its own separate post, consider the possible pandemic ramifications? Thank you in advance for considering it. AnnieRN
AnnieRN: OK. I'll post on it tomorrow.