Here is the world pandemic flu report for today. It consists of the WHO report dated July 1, 2009 plus the latest reports from Australia, Canada and the United States and other countries marked in this color. The totals are those posted at those sites at the time this report was produced. Those sites will change as they receive new data. We will post a new report as we are able.

408 cases reported. 256 deaths. World Health Organization

NOTE I think this may be very important. Indonesia has reported no new cases in 2009, despite having the largest number of cases and the highest death rate. Has the feud between WHO and the Indonesian government resulted in them withholding information as well as samples?

Reports of infection in Indonesian poultry

Avian influenza has struck a second district in Bali despite efforts to contain the spread of the disease on the island, the district’s animal husbandry, marine and fisheries agency said on Friday.

I Gusti Ngurah Sandjada, the head of the agency in Jembrana district in western Bali, said the outbreak was discovered after 52 chickens in the village of Banyubiru died over the course of four days.

“We immediately conducted a rapid test and found that the chickens were infected with the H5N1 virus,” Sandjada said. [snip]

Meanwhile, state-run Antara news agency reported on Friday that bird flu cases had been reported in 11 subdistricts in Banyuwangi, at the easternmost tip of Java Island. Since January, 932 chickens were killed by the virus, the highest number of chicken deaths due to bird flu ever recorded in East Java Province.

Dewa Made Ngurah, the head of the animal husbandry, marine and fisheries agency in Bali’s provincial capital of Denpasar, said that many birds were smuggled from Banyuwangi to Bali despite a 2005 bylaw prohibiting the unregulated flow of poultry in and out of the province.

China appears to be the focal point for avian flu [H5N1] cases so far in 2009. Of 9 reported cases, 7 are from China. Nearly all are reported to have had contact with poultry.

In Third World nations, especially rural regions, when livestock become sick, the rush is to slaughter them and perhaps use them before they die. Since H5N1 is primarily transmitted through contact with infected poultry, this means that every sick bird is a tiny hotspot of infection.

Here are the latest two reports from China.

WHO update 3

27 January 2009 — The Ministry of Health in China has announced three new confirmed human cases of H5N1 infection. The first, a 31-year-old female from Urumqi, Xinjiang Autonomous Region had onset of symptoms on 10 January. She received treatment in hospital but died on 23 January. Investigations into the possible source of her infection indicate recent visits to a live poultry market. The local authorities are currently conducting epidemiological investigations and close contacts are being monitored. To date, no clinical symptoms have been reported among the contacts.

The second case is a 29-year-old male from Guiyang city, Guizhou. He had onset of symptoms on 15 January and remains in a critical condition. Investigations into the source of his infection indicate possible exposure at poultry market.

The third case is an 18-year-old male from Beiliu City, Guangxi Province. He had onset of symptoms on 19 January and died on 26 January. Investigations into the source of his infection indicate a recent history of exposure to sick and dead poultry. Close contacts of the case are being monitored and to date all remain well.

Of the 37 cases confirmed to date in China, 25 have been fatal.

WHO update 4

2 February 2009 — The Ministry of Health in China has announced a new confirmed human cases of H5N1 infection. The case is a 21-year-old female from Xupu County, Hunan province. She had onset of symptoms on 23 January and remains in hospital in a clinically stable condition. Investigations into the source of her infection indicate possible exposure to sick and dead poultry.

Of the 38 cases confirmed to date in China, 25 have been fatal.

In 2009, there have been 9 cases reported, with 4 being fatal. Since the disease became contagious to humans, there have been 404 cases with 254 being fatal. WHO table

A Facebook conversation prompts me to examine the current situation with the A type H5N1 influenza virus, known as “bird flu” or “avian flu”. Birds suffer from several types of influenza, however, and most are not contagious for humans. The terms “bird flu” and “avian flu” are, thus, very non-specific.

A)H5N1 is the influenza virus that was discovered in Scotland, in birds, in 1959. It was first seen in humans in 1997, after 1996-97 outbreaks in birds in China and Hong Kong.

To date, the World Health Organization is reporting 397 cases, of which 249 were fatalities. 63% of the reported cases were fatal.

Indonesia has had the most cases and one of the highest death rates at 81%. Vietnam runs second, and its death rate is 49%. 12 countries in Asia and three in Africa have reported human cases of A)H5N1.

The number of cases peaked in 2006 and dropped in both 2007 and 2008. Several notions occur when examining the geographical spread of H5N1 in humans and in birds.

There are large geographical areas where no avian infection have been reported separating areas where they have. This suggests that the countries involved lack the capability to discover infections, or are not reporting them. Given the dictatorial nature of most of the governments in the “blank” areas, one would lean towards non-reporting as a reason.

You will also note the odd distribution in China. The populous and wealthy coast has no cases. China lied repeatedly about SARS and it is very possible that they are lying about H5N1.

There have been several clusters of H5N1 that suggest human to human transmission [ H2H ]. One such, from Indonesia, involves an extended family that spent time with and cared for a dying relative in a small room. Close, intimate contact may transmit the disease, however that are far more intimate contacts that did not contract H5N1 so it may just be one variant that is contagious.

To date, the overwhelming number of cases involve people in rural areas who have close, daily contact with poultry. The handling of sick birds, the slaughter and preparation of sick birds and the common practice of keeping poultry in living quarters all provide ample opportunity for infections. Since women and children usually farm the poultry, they are the primary population to become sick.

It has only been in the last year to two that laboratories in East Asia were certified to be able to test for H5N1. Prior to that, the samples had to be sent to WHO labs or to labs in the West with testing capability. News reports based upon local tests from several years ago are not reliable indicators for the spread of H5N1.

Progress on a vaccine is being made. The virus is continually changing and more than one variant is responsible for human illnesses. Nine “clades” have been isolated, 0-9, and sub-clades and variants within the sub-clades. Clades 1, 2.1, 2.2 and 2.234 have caused human cases.

WHO is building a stockpile of H5N1 vaccines, and 9 different versions were approved as of September 2008. More were pending but the genetic properties of H5N1 have been varying enough that many variants do not have vaccine programs proposed for them as yet.

Because of the small number of actual cases, the WHO does not have good data on the effects of any vaccine in a human population. Animal studies suggest that vaccines can be effective, and that their ability to produce antibodies can be safely improved upon with vaccine additives. Without knowing which H5N1 clade, sub-clade or variant will produce the predicted pandemic, production of vaccines is driven more by the variant appearing in a given region than a world-wide threat.

That said, the WHO recognizes the difficulty of delivering vaccines to rural, remote regions. Some of the cases in Indonesia could only be reached on donkey back, for example. The polio outbreak in 2006 and 2007 that was caused by Islamic teachers in Nigeria refusing to allow vaccinations to take place suggests yet another reason that WHO plans for the Third World will have to be vastly different than those for the West.

There are at least four separate versions of H5N1 that are producing illness in humans. In all less than 400 total cases have been seen. Many of the countries in the region affected by outbreaks in birds have governments that control the news and are not forthcoming about many of the events in their nations.

I continue to believe that there is no evidence that H5N1 will produce the next influenza pandemic. The Spanish Flu version, H1N1, is in circulation and has equally as much of a chance, perhaps more since tens of thousands more cases of H1N1 happen in humans every year.

I also continue to believe that there is no evidence that the next influenza pandemic will be any deadlier than the last two. We have good data on two, and poor data on a third, and that suggests to me that we do not have enough information to make any assumptions about future pandemics.

You may find all my work on H5N1 at this category link: Avian Flu.

Bird flu cases, deaths and survivals

WHO table for all cases through January 7, 2009

China

The Ministry of Health in China has reported a new case of human infection with the H5N1 avian influenza virus. The case is a 19-year old female from Chaoyang District, Beijing. She developed symptoms on 24 Dec 2008, was hospitalized, and died on 5 January 2009.

The case was confirmed by the national laboratory. The case had contact with poultry prior to her illness. All contacts have been placed under medical observation. All remain healthy to date.

Of the 31 cases confirmed to date in China, 21 have been fatal.

Vietnam

The Ministry of Health in Viet Nam has reported a new confirmed case of human infection with the H5N1 avian influenza virus. The case has been confirmed at the National Institute of Hygiene and Epidemiology (NIHE).

The case is an 8-year old girl from Dien Trung commune, Ba Thuoc district, Thanh Hoa province. She developed symptoms on 27 December 2008 and was hospitalized on 2 January 2009. She is currently in a stable condition. The case is known to have had recent contact with sick and dead poultry prior to the onset of her illness.

Further investigations are currently underway. Control measures have been implemented and close contacts are being identified and monitored.

Of the 107 cases confirmed to date in Viet Nam, 52 have been fatal.

Reuters

The H5N1 bird flu virus may sometimes stick to surfaces or get kicked up in fertilizer dust to infect people, according to a World Health Organization report published on Wednesday.

The WHO team reviewed all known human cases of avian influenza, which has infected 350 people in 14 countries and killed 217 of them since 2003, and found that 25 percent of cases have no explanation.

Most are passed directly from bird to people, they noted in their report, published in the New England Journal of Medicine. And very rarely one person can infect another — always close relatives via intimate physical contact.

“In one quarter or more of patients with influenza A (H5N1) virus infection, the source of exposure is unclear, and environment-to-human transmission remains possible,” the researchers, led by WHO’s Dr. Frederick Hayden, wrote.

“For some patients, the only identified risk factor was visiting a live-poultry market.”

It could be that small particles of virus-contaminated fluid stuck to surfaces, they said. Or perhaps fertilizer made from infected bird feces somehow carried the virus into people’s noses or mouths.

“It is unknown whether influenza A (H5N1) virus infection can begin in the human gastrointestinal tract,” they wrote.

“In several patients, diarrheal disease preceded respiratory symptoms, and virus has been detected in feces.”

Government and health officials have stressed that well-cooked chicken cannot infect people. “Drinking potable water and eating properly cooked foods are not considered to be risk factors, but ingestion of virus-contaminated products or swimming or bathing in virus-contaminated water might pose a risk,” the WHO team of bird flu experts noted.

More at the link

As is the normal procedure, the samples here have been sent to a lab capable of accurately determining if it is bird flu. Local labs are wrong 50% plus of the time.

WHO

The Ministry of Health in Pakistan has informed WHO of 8 suspected human cases of H5N1 avian influenza infection in the Peshawar area of the country. These cases were detected following a series of culling operations in response to outbreaks of H5N1 in poultry. One of the cases has now recovered and a further two suspected cases have since died.

Samples taken from the suspected cases have tested positive for H5N1 in the national laboratory and are being forwarded to a WHO H5 Reference Laboratory for confirmation and further analysis. The MoH is taking steps to investigate and contain this event, including case isolation and contact tracing and monitoring, detailed epidemiological investigations, providing oseltamivir for case management and prophylaxis, reviewing hospital infection control measures and enhancing health care-based and community-based surveillance for acute respiratory infections.

WHO is providing technical support to the MoH in epidemiological investigations, reviewing the surveillance, prevention and control measures that have been implemented and carrying out viral sequencing of avian and human isolates.

Multiple poultry outbreaks of H5N1 influenza have been occurring in Pakistan since 2006. In 2007, there have also been outbreaks in wild birds. A majority of the outbreaks discovered have been in the ‘poultry belt’ of North-West Frontier Province, particularly in the Abbottabad and Mansehra area and cases of infection in wild birds have been identified in the Islamabad Capital Territory.

World Health Organization

Two items from Reuters, France and Germany

France confirms H5N1 flu virus in swans

PARIS, July 5 (Reuters) – Tests have confirmed that three swans found dead in eastern France were killed by the H5N1 bird flu virus, the French agriculture ministry said on Thursday, France’s first cases of the disease in over a year.

The government raised its alert level to “high” as a result, meaning that birds and poultry in mainland France will either have to be locked up or protected by nets to avoid all contact with wild birds, a ministry official said.

Pigeon races and other events where birds are gathered will be forbidden.

“Michel Barnier, minister of agriculture and fishing, is putting in place the risk-prevention measures corresponding to the shift from the ‘moderate’ level to the ‘high’ level,” the ministry said in a statement.

Germany said it was raising its assessment of the risk of bird flu following the French announcement and after officials on Wednesday discovered more birds that had died of the H5N1 virus, this time in the eastern state of Thuringia.

Spain’s Ministry of Agriculture, Fisheries and Food on Thursday asked veterinary services to be more vigilant in the outlook for possible bird flu cases.

Spain already bans hunting with decoys, outdoor poultry raising and the isolation of breeding areas for wild aquatic birds in high-risk zones like bird migatory paths and wetlands.

In 98 regions in France classed as at risk — some 15 percent of the country — there will be special veterinary checks at poultry farms.

Germany raises bird flu threat level

BERLIN, July 5 (Reuters) – Germany is raising its assessment of the risk of bird flu after officials in France and Germany discovered more birds which had died of the H5N1 virus, the country’s top state veterinary laboratory said on Thursday. “We will raise the threat level,” said a spokeswoman for the Friedrich Loeffler Institute.

She cited the news from Wednesday that more wild birds had tested positive for the lethal strain of H5N1 bird flu in Germany — this time in the eastern state of Thuringia.

In addition, France confirmed its first cases of the disease in over a year earlier on Thursday, she noted.

The assessment level affects the measures the government and local authorities take to prevent bird flu, such as keeping birds to confined areas.

Germany’s federal states on Thursday agreed they would not ease rules on keeping poultry indoors as had been planned in Friday’s session of the upper house, or Bundesrat, where the states are represented.

It looks like some accomodations have been made by WHO concerning Indonesia.

WHO

WHO can now confirm 15 additional cases, including 13 deaths of human infection with H5N1 avian influenza that occurred in Indonesia from the end of January 2007 up to the present and has updated its table of confirmed human cases accordingly.

Testing for H5N1 influenza virus infections is not done routinely by many laboratories and among the laboratories that do test for H5N1, experience and levels of diagnostic capacities can vary. (see WHO criteria) WHO had previously required external confirmation of laboratory results from Indonesia, but following a formal on-site assessment of the capacity of national laboratory in Jakarta to diagnose H5 avian influenza viruses, WHO will now accept the results from the national laboratory, in collaboration with the Eijkman Institute without further external confirmation.

The assessment was carried out by a WHO team of virologists and laboratory scientists from the WHO Collaborating Centre in Tokyo, Japan, the national influenza centres of India and Thailand, the WHO Regional Office for South-East Asia and the WHO Country Office of Indonesia.

The following additional cases of human infection with H5N1 avian influenza have been confirmed. Seven of these cases had exposure to sick or dead poultry; the source of infection is unknown for eight cases.

All but two cases were fatal.

Anthony Fauci, head of the U.S. National Institute of Allergy and Infectious Diseases, can be a poopy head at times, but he is very correct in this Reuters article.

While many health experts see the H5N1 bird flu virus as a likely cause for an influenza pandemic, another influenza virus could just as likely mutate into a global killer, U.S. health experts said on Tuesday.

“You can not accurately predict if and when a given virus will become a pandemic virus,” said Anthony Fauci, head of the U.S. National Institute of Allergy and Infectious Diseases.

Fauci said too little is known about exactly how and when a virus will mutate. Focusing too much on one suspect — even a very likely suspect such as H5N1 — may be a mistake.

WHO

Since the last meeting in Hanoi, May 2005, eight new countries have reported human infections with avian influenza A(H5N1) viruses. Clinicians, epidemiologists, virologists and public health specialists from the countries with human cases, and experts in pulmonary medicine, critical care, and influenza attended the meeting to share their experiences.

Participants agreed that standardizing care and promptly sharing clinical and treatment information are critically important to understanding the disease in humans and to improving clinical management.

Observations and experiences, including unpublished data, were shared by participants during the consultation. Several conclusions regarding management of patients with H5N1 illness support and expand current WHO guidance.

• Experiences with early oseltamivir treatment suggest its usefulness in reducing H5N1-associated mortality. In addition, evidence of prolonged H5N1 virus replication indicates that treatment is warranted even with late presentation.

• As previously discussed, modified regimens of oseltamivir treatment, including two-fold higher dosage, longer duration and possibly combination therapy with amantadine (in countries where the H5N1 virus is susceptible to amantadine) may be considered on a case by case basis, especially in patients with pneumonia or progressive disease. Ideally this should be done in the context of prospective data collection.

• Corticosteroid therapy has failed so far to show effectiveness, and prolonged or high dose corticosteroids can result in serious adverse events in H5N1 patients, including opportunistic infection. Corticosteroids should not be used routinely, except for persistent septic shock with suspected adrenal insufficiency.

• Antibiotic prophylaxis should not be used. When pneumonia is present, antibiotic treatment is appropriate initially for community-acquired pneumonia according to published evidence-based guidelines. When available, the results of microbiologic studies should be used to guide antibiotic usage in patients with A(H5N1) infection.

• Therapy for H5N1-associated ARDS should be based upon published evidence-based guidelines for sepsis-associated ARDS, specifically including lung protective mechanical ventilation with low tidal volume.

The observations from the meeting will be published in greater detail, as an updated WHO guidance on H5N1 clinical management followed by a meeting summary in the form of peer-reviewed article in the scientific literature.

WHO

The Egyptian Ministry of Health and Population has announced a new human case of avian influenza A(H5N1) virus infection. The case was confirmed by the Egyptian Central Public Health Laboratory and by the US Naval Medical Research Unit No.3 (NAMRU-3).

The 5-year-old boy from Sharkia Governorate was admitted to hospital with symptoms on 14 February, and his condition remains stable. The boy was exposed to sick birds one week prior to the onset of symptoms. Contacts of the boy remain healthy and have been placed under close observation.

Of the 22 cases confirmed to date in Egypt, 13 have been fatal.

Here are some snips from the article. Worth a look. The usual doomsayers, Osterholm and Webster, get the big quotes. My take at the end of the piece.

IHT

“I’ve gotten at least 10 media calls in the last few months asking me to deliver the death sentence for avian flu,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “But at any conference, if you get a group of virologists at the bar, after the fourth beer, they let their hair down and admit it — they don’t know what is happening. They’ve been incredibly humbled by this virus.”

Robert Webster, a virologist at St. Jude’s Children’s Research Hospital in Memphis, ended a talk with a slide of three animals in a reference to Asia. “We’ve survived the Year of the Chicken and the Year of the Dog,” he said. “Will we survive the Year of the Pig?”

The Year of the Pig begins Sunday, and the Lunar New Year celebrations in China and Vietnam have become associated with flu outbreaks because so much poultry for family feasts is on the move. “My take-home message,” Webster added, “is don’t become complacent. Don’t trust this one.”

But the virus is out of control in poultry in three countries — Indonesia, Nigeria and Egypt — with combined populations of 447 million people. A year ago, it was out of control only in Indonesia, and Thailand and Vietnam had stifled outbreaks, although the virus returned. China remains a mystery — despite official denials, there is evidence that it is circulating there.

Most alarming to the experts, although it got relatively less attention, was the death last month of a 22-year-old Nigerian woman, an accountant who lived in the crowded financial capital, Lagos.

Officially, only one death from H5N1 was confirmed, but Nigerian newspapers said the woman’s mother died with similar symptoms two weeks earlier, and a female relative was sick but recovered. If true, that suggests a cluster of cases with possible human-to-human transmission. Tests on them were negative, but human H5N1 tests are best done on fresh samples from deep in the lungs, which are hard to obtain, and false negatives are common.

In Nigeria, despite the culling of 700,000 birds, the flu has been found in 19 of 36 states, said the UN Food and Agriculture Organization.

Oyedele Oyediji, president of a Nigerian veterinarians’ association, told local newspapers that bans on poultry movement and culling orders were simply not being enforced. “If you go to the markets in Lagos now,” he said, “you would notice that poultry products like guinea fowl, ducks, turkey and chicken from the northern part of the country are still available.”

Nigerian farmers have complained that government cullers pay them only $2 for chickens that cost them $5 to $7 to raise. But payments, supported by the World Bank, seem to be made fairly promptly through local police stations.

Indonesia, by contrast, provides farmers with $1 vouchers that may not be cashed for three or four months, said Tri Satya Putri Naipospos, the country’s chief veterinarian. “It’s our weakest implementation,” she admitted. “It should be treated as an emergency, but we still follow routine budget mechanisms.”

Eighty percent of all Indonesian households keep poultry, she said, the flu is in 30 of 33 provinces and still few take the threat seriously enough. “Farmers say dying chickens are normal in life,” she said. “And you must realize that 62 dead people in one and a half years? That’s not very much in Indonesia. Three hundred thousand die from TB, from dengue. People in the villages don’t grab what is a pandemic.”

World Health Organization reports almost always link human cases to proximity to dead poultry, but Naipospos, the Indonesian flu expert, released data at a flu conference in Washington on Feb. 1 calling that into question. In the 82 human cases studied, she said, only 45 percent of victims had direct exposure to sick poultry.

An additional 35 percent had “indirect” exposure, which meant sick birds in the neighborhood, and 20 percent were “inconclusive.” “Unlike in Thailand and Vietnam,” she said, “our risk factors are not clear.” Virologists believe that the situation that must be avoided at all costs is to have humans with seasonal flu catch H5N1, too, because the viruses could mix.

Indonesia’s best prevention against that, Naipospos said, is the “Tamiflu blanket.” “We learned that in Garut,” she said of a cluster of cases last August in West Java. More than 20 people died or suffered serious symptoms.

The government quickly gave the antiviral drug to more than 2,000 people.

Ultimately, only three cases in the cluster were confirmed, but scientists suspected some were missed and the drug suppressed the virus to undetectable levels in others.

Despite what the learned doctors say, it may be that the ordinary Indonesian is correct. 62 versus 300,000. It is not a big deal at this time and may never be.

Let’s be very realistic. If this becomes a pandemic, there’s not a damn thing we can do about the millions who will die in the Third World. Tamiflu is not 100% effective, and it must be given daily for the life of the pandemic. There just aren’t that many doses and there will not be. Even if the medicine exists, religious and social restrictions will come in to play, just as the Moslems limiting the polio vaccinations in Nigeria created an epidemic throughout Africa and Asia.

And, just how do you propose to deliver this medicine? Bad weather, bad roads, not enough medical personnel.

However, if Drs. Osterholm and Webster could just get a few million more dollars for research, we may all be saved.

WHO

6 February 2007

The Egyptian Ministry of Health and Population has announced a new human case of avian influenza A(H5N1) virus infection. The case was confirmed by the Egyptian Central Public Health Laboratory and by the US Naval Medical Research Unit No.3 (NAMRU-3).

The 17-year-old female from Fayyoum Governorate developed symptoms on 25 January 2007 and was initially treated for seasonal influenza. She was hospitalized on 1 February with fever and breathing difficulties, and died on 2 February. Initial investigations into the source of her exposure indicate the presence of sick and dead poultry at her home in the days prior to the onset of symptoms.

Of the 20 cases confirmed to date in Egypt, 12 have been fatal.