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Pitsel Pandemic News (01|29|09)

What Do We Hear? and What Does It Mean?

China has announced its fifth human death this year from the H5N1 virus, commonly called "bird flu".

Even before the latest deaths, Chinese health officials began increasing vigilance against the virus. Does it make you wonder what they know that we don't? Perhaps it should. They are still reporting, and I underline the word reporting because we can't ever be sure of what isn't reported, that the H5N1 strain of flu remains largely a virus among birds.

The recent flu incidents in humans occurred in 4 different provinces and appear to be unconnected. In all cases, there is evidence of contact with diseased poultry. They claim no evidence of human-to-human transmission of infection. Underline the word claim, even though at Pitsel & Associates, Ltd. we are not at all cynical about Government reporting.

Let's look at what we know about the disease, about questionable test procedures in some areas, complications that arise from rural isolation, and about politics. ProMed is an legitimate and mainstream infectious disease newsletter that is widely read by media writers and the lay public who have minimal background in infectious diseases. ProMed reports some interesting situations with regard to human cases of H5N1.

The evidence that health authorities are looking for to establish that the H5N1 virus has indeed passed from human to human, and not just from birds to humans, is a time delay between disease onset in more than two people after contact with an "index" case (the person with the original infection, perhaps the one handling the birds).

Testing procedures to confirm evidence of H5N1 in humans, in many areas, is appalling. Gaps in the "scientific method" are often falling into one or more of several categories. Viral samples are frequently not collected from the index case, making disease tracking unreliable or impossible. False negatives and misdiagnosis are common. Testing procedures are frequently absent or faulty. Cases of the disease are sometimes, and we'll never know how often, not submitted for testing because of distance to facilities, expense, knowledge, and/or access. Mis-reporting, or non-reporting, may be intentional and due to political pressures to protect the economy; or, it may be unintentional as when cases develop far from treatment and testing centers, and deaths are attributed to any number of other causes.

A Vietnamese man in 2004 became ill and died with flu symptoms in the hospital, but was never tested for H5N1. His two sisters who cared for him each developed symptoms on the same day as each other, and initially tested as "inconclusive" for H5N1. They were later hospitalized, together on the same day, and were retested and confirmed to have H5N1. They subsequently died within an hour of each other.

The New England Journal of Medicine reported that same year in Thailand an index case who was living with her aunt, hundreds of miles from Bangkok. Her mother worked in an office in Bangkok and had no exposure to poultry. The index case developed symptoms after burying a pet bird, but was diagnosed as having dengue fever. The mother visited her daughter in the hospital without observing any extra health precautions. After the index case died the mother returned to Bangkok and became ill with the same symptoms, but was not tested, even though her daughter had just died with flu-like symptoms. The aunt developed the same symptoms as well and tested negative, but was positive on a re-test. The mother was subsequently re-tested and identified with H5N1. The Index case was never tested for H5N1, despite her symptoms, and subsequent death.

These stories reflect similar confirmed cases in Cambodia, Sumatra, and a notable example of a cluster in Karo, in 2006, where the index case infected five family members including one brother who went on further to infect his son. That H2H2H (human to human to human) cluster was easily identified, but NO sample was collected, so no official confirmation of H5N1 outbreak.

An even larger example in 2006 involved three independent clusters with an H5N1 confirmed case in each cluster. However, none of the index cases from any of the three clusters were tested, and all died.

Indonesia more recently has ignored an obvious mis-diagnosis in cluster members, even after H5N1 has been confirmed. A series of such clusters involving fatal infections in index cases were identified as lung inflammation, dengue fever, and typhus following a news blackout and reporting delays.

False negatives resulted from 21 degraded samples sent from Turkey to Britain for confirmation where only 12 could be confirmed because of the condition of the samples. The number of negative test results due to failure to collect or preserve samples, or inappropriate testing procedures, coupled with many incidents of misdiagnosis, has led to an under-count of official clusters.

The ProMed commentary further claims that recent clusters such as those in Hunan and Vietnam have clear evidence of human to human transmission, even though samples from the index cases were not collected.

What does this mean? It's a reasonable conclusion that, combined with the news from China of another confirmed death from H5N1, and the above un-reported incidents, that there is under-reporting of this situation. It would also be reasonable to conclude that by the time we are officially informed that we have entered Phase 4 of the pandemic we have seriously underestimated the scope of the infection, and significantly reduced our time to prepare, and are in much deeper trouble than we realized.

This is just a reminder that the Preparation Challenge for WEEK 2 is simply to stock up on oral-re hydration formula (or its ingredients), thermometer and alcohol, prescriptions, pain and fever reducers, vitamins, and hand sanitizers.

Stay well. Take care.

© 2009, Pitsel and Associates Ltd.
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