From the beginning of the year, the province of Quang Tri several outbreaks occur in poultry farming in Hai Lang district, Vinh Linh, Gio Linh. Beginning in June alone, there have been four outbreaks of avian flock of 7 on 9 households in Hai Lang district and Gio Linh district.
By this time in Quang Tri province has more than 23,000 children have been infected poultry culled. Next time, SDAH Quang Tri continue vaccinating 1 million doses of vaccine in poultry in all districts and cities in the province, especially in risk areas of high bird flu outbreak. Information on VNA.
Saturday, August 20, 2011
CDC Asks to Sample Virginia Waters for Deadly Amoebaba
Published August 20, 2011
RICHMOND, Va. – Federal authorities are asking for samples of Virginia waterways in an attempt to develop a test for detecting deadly microscopic amoeba.
Health officials say two children and a young man nationwide have died this summer from a fatal infection known as primary amoebic meningoencephalitis stemming from a brain-eating amoeba that lives in water.This month, a 9-year-old Virginia boy died a week after he went to a fishing day camp. Christian Alexander Strickland had visited several bodies of water during
The Richmond Times-Dispatch reports that The Centers for Disease Control and Prevention is asking Virginia for help to sample waters for Naegleria fowleri.
The free-living amoeba gets up the nose, burrows up into the skull and destroys brain tissue. It's found in warm lakes and rivers during the hot summer months, mostly in the South."It's a terrible disease that we would like to know more about and be able to tell the public more about from a prevention standpoint," said Michael Beach, the federal agency's associate director for healthy water. "We are trying to learn more, but it's a tough one because it's such a rare occurrence."
It's a medical mystery why some people who swim in amoeba-containing water get the fatal nervous system condition while many others don't, experts say."That's the million-dollar question," he said. "We have no idea."....
Vietnam: Prevention H5N1 Hanoi
"Management" tight to prevent disease outbreaks in poultry
Hanoi Department of Animal Health and Veterinary Station facilities have enhanced inspection of eggs supply, sanitation and veterinary facility for professional organizations and hatching eggs, providing bulk seed to farmers in Hanoi and other provinces and neighboring cities.
Department of Animal Health in Hanoi, said: In the area of poultry production scale in suburban areas, farmers tend to expand farming, increasing rapidly to meet market demand in the months. However, before the weather with rain and sunshine mix, very high humidity caused disease outbreaks in the herds. In recent days, bird flu has reappeared in several provinces to farmers in Hanoi as not subjective, neglected stage of disease prevention for pets.
Therefore, the Hanoi Department of Animal Health and Veterinary Station facilities have enhanced inspection of eggs supply, sanitation and veterinary facility for professional organizations and hatching eggs, provided large number of seeds to farmers in Hanoi and other provinces and neighboring cities. Also timely handling of cases of transportation and trading of poultry and poultry products of unknown origin, did not have enough valid quarantine certificate and suspension facilities hatching eggs are not eligible veterinary hygiene
Particularly in Phu Xuyen district, where more than 100 establishments specialized in breeding birds on a large scale, Department of Animal Health in Hanoi to coordinate with local government training for all under-hatched regulations the law on veterinary services, hygienic conditions during the import of poultry eggs, hatching into the oven and selling animals.
Hanoi Department of Animal Health and Veterinary Department suggested the provinces and neighboring cities shall regularly exchange information about the disease situation, a list of households specializing in transportation of cattle, poultry in Hanoi and from Hanoi to other provinces as well as large numbers of violations for coordinated management.
According to the Department of Veterinary City: Hanoi which provide seed sources for large poultry breeding areas of the capital and provinces nearby. Only in Phu Xuyen district - which they call the "oven" to provide the same bird under the largest has almost 500 incubators are operating at full capacity, each year provides hundreds of thousands of birds like the country farmers
Friday, August 19, 2011
Cambodian girl dies from H5N1 infection
Lisa Schnirring 
Aug 19, 2011 (CIDRAP News) – Cambodia's health ministry has confirmed that a 6-year-old girl died from an H5N1 avian influenza infection, the World Health Organization (WHO) announced today.
The girl, from Kampong Cham province in eastern Cambodia, got sick Aug 7 and was first treated by local healthcare providers, the WHO said. After her condition didn't improve she was admitted to Kantha Bopha Children's Hospital in Phnom Penh on Aug 12, where she died 2 days later.
Her infection and death raise Cambodia's H5N1 toll to 18 cases and 16 deaths, the WHO said.
Cambodia has reported eight H5N1 cases this year, all of them fatal. Though a recent report from German researchers noted that the overall case-fatality rate for the disease has declined over the past 5 years, it has been lethal in Cambodia, which reported its first cases in 2005 and has had only two patients who survived their infections.
Cambodia's latest case raises the world's H5N1 total to 565 cases, which include 331 deaths.
An investigation into the source of the girl's illness suggests that she had been exposed to sick poultry. There were recent reports of poultry die-offs in the girl's village.
National and local response teams are conducting an outbreak investigation, according to the WHO report. So far none of the girl's contacts have tested positive for the H5N1 virus.
Tuesday, August 16, 2011
World too complacent on bird flu
Last week, Egyptian officials reported to the World Health Organization that a 6-year-old girl was successfully treated for avian influenza, which she is suspected to have contracted as a result of exposure to diseased poultry. A week earlier Cambodian officials confirmed that a 4-year-old girl from a farming village in that country died of avian influenza after being exposed to an infected chicken. According to World Health Organization statistics, these girls are the 563rd and 564th humans to be infected with bird flu, and the Cambodian girl was the 330th to die of it.
Most remarkable about these cases are just how unremarkable it has become to learn that bird flu has jumped the species barrier. When it first became apparent that avian influenza took a human life in Hong Kong in 1997, it was big news. The Centers for Disease Control and Prevention mobilized experts to conduct an on-site investigation. WHO officials went into crisis mode. And newspapers around the world reported on the events.Since then, bird flu has become endemic among poultry in many countries, including China, Indonesia, Egypt and Vietnam, and it has killed nearly 60 percent of the humans it has infected. Nonetheless, the reports during the past two weeks of two recent infections and another death raised little concern except among public health officials.
The fact that bird flu in developing nations receives little public attention reveals that the world has become complacent about this threat. Not that we have been sitting idle. Countries have pledged more than $4 billion to combating bird flu since 2005, and developing nations have....
Vietnam - Avian influenza outbreaks have very high risk
16/08/2011 20:55:00
Spray disinfection of poultry trade in the region.
At its meeting the National Steering Committee for Avian Influenza Prevention pm 16 / 8, Hoang Van Nam, Director General for Animal Health warned that the risk of outbreak of new bird flu outbreak in this period is very high if the local does not control the outbreak, lax supervision of shipping and integrated disease prevention.
Weather changes, unexpected developments in the many poultry reduced resistance also causes an increased risk of contributing to the spread of disease.
Steering Committee of local requirements enhance communication to farmers, trade, slaughter and consumption of poultry to reduce risk behaviors arise and spread. Also, the local implementation of synchronous prevention services such as livestock biosecurity, hygiene organizations, disinfection, sterilization livestock sector, the transport, slaughter and trade in poultry market especially from areas with outbreaks.
So far, the country also two provincial bird flu is less than 21 days Nghe An and Quang Tri.
In Nghe An, translations appeared in 11 communes and towns of the four Nghi Loc district, Dien Chau, Yen Thanh Hung Nguyen, and with the total number of birds killed and destroyed more than 8,000 children. In Quang Tri, avian influenza appears in the small farming households in Gio Linh district of the total bird deaths and the destruction of nearly 1,000. Avian influenza occurs in the two provinces mainly on ducks.
Ministry of Agriculture and Rural Development has made two provinces on vaccines for RE5 to serve prevention.
As reported by the Veterinary Department, blue ear disease and foot and mouth disease in cattle is temporarily controlled the whole country, not a locality notice is translated.
Spray disinfection of poultry trade in the region.
At its meeting the National Steering Committee for Avian Influenza Prevention pm 16 / 8, Hoang Van Nam, Director General for Animal Health warned that the risk of outbreak of new bird flu outbreak in this period is very high if the local does not control the outbreak, lax supervision of shipping and integrated disease prevention.
Weather changes, unexpected developments in the many poultry reduced resistance also causes an increased risk of contributing to the spread of disease.
Steering Committee of local requirements enhance communication to farmers, trade, slaughter and consumption of poultry to reduce risk behaviors arise and spread. Also, the local implementation of synchronous prevention services such as livestock biosecurity, hygiene organizations, disinfection, sterilization livestock sector, the transport, slaughter and trade in poultry market especially from areas with outbreaks.
So far, the country also two provincial bird flu is less than 21 days Nghe An and Quang Tri.
In Nghe An, translations appeared in 11 communes and towns of the four Nghi Loc district, Dien Chau, Yen Thanh Hung Nguyen, and with the total number of birds killed and destroyed more than 8,000 children. In Quang Tri, avian influenza appears in the small farming households in Gio Linh district of the total bird deaths and the destruction of nearly 1,000. Avian influenza occurs in the two provinces mainly on ducks.
Ministry of Agriculture and Rural Development has made two provinces on vaccines for RE5 to serve prevention.
As reported by the Veterinary Department, blue ear disease and foot and mouth disease in cattle is temporarily controlled the whole country, not a locality notice is translated.
Avian influenza outbreak in eight communes and towns of Quang Politics
SDAH Ha Tinh province, said the province has more than five million birds, but more than a million children have been vaccinated by the lack of bird flu vaccine. Room service initiative, the province increased control of the trading and transportation of poultry from the province of Nghe An and Quang Binh. National Highway 1A, set up two checkpoints in the south of Ben Thuy bridge, north of Pass Horizontal. At the same time ending up second in Tien Son commune, Huong Son Commune Lien Minh, Duc Tho district of Ho Chi Minh. As of 16-8, the area eight communes and towns, the two districts of Gio Linh and Hai Lang (Quang Tri) has more than 23 thousand poultry deaths and destruction caused by avian influenza. In the village States Truc, Quang Gio (Gio Linh) appear more new outbreak on a flock of 600 children households. Through the test results positive for influenza virus H5N1.Chi provincial Veterinary Bureau has coordinated the districts to monitor and monitored flocks, prohibits the sale and transportation of poultry from areas.
More than 23,000 avian influenza A/H5N1 infection
Tuesday, 16/08/2011 18:04
ANTD - 16-8 Day, from Veterinary Bureau said Quang Tri Province, to the present time the province had 23,120 birds have died and destruction caused by influenza A/H5N1 infection. The number of infected poultry is concentrated in eight communes and towns in two districts of Gio Linh and Hai Lang.
Shortly after the outbreak, SDAH Quang Tri was quickly coordinate with the local implementing disease control measures, the total destruction of infected poultry; emergency vaccination on herd animals in two districts of Gio Linh Hai Lang and simultaneously prepare for vaccinating the entire poultry in the province.
By this time, Hai Lang district did not detect more poultry outbreaks, Gio Linh district separately discovered a new outbreak on the household's flock 600 Hoang Van Vinh village States Architecture, Gio Quang, check survey results were positive for H5N1 virus.
The Quang Tri province is leading the local monitoring and surveillance of poultry at local, prohibited the sale and transportation of poultry in the epidemic areas, conduct and reporting process as soon as you sign Disease name
ANTD - 16-8 Day, from Veterinary Bureau said Quang Tri Province, to the present time the province had 23,120 birds have died and destruction caused by influenza A/H5N1 infection. The number of infected poultry is concentrated in eight communes and towns in two districts of Gio Linh and Hai Lang.
Shortly after the outbreak, SDAH Quang Tri was quickly coordinate with the local implementing disease control measures, the total destruction of infected poultry; emergency vaccination on herd animals in two districts of Gio Linh Hai Lang and simultaneously prepare for vaccinating the entire poultry in the province.
By this time, Hai Lang district did not detect more poultry outbreaks, Gio Linh district separately discovered a new outbreak on the household's flock 600 Hoang Van Vinh village States Architecture, Gio Quang, check survey results were positive for H5N1 virus.
The Quang Tri province is leading the local monitoring and surveillance of poultry at local, prohibited the sale and transportation of poultry in the epidemic areas, conduct and reporting process as soon as you sign Disease name
Eurosurvellance: Avian influenza A(H5N1) in humans: new insights from a line list of World Health Organization confirmed cases
Eurosurveillance, Volume 16, Issue 32, 11 August 2011
Research articles
Avian influenza A(H5N1) in humans: new insights from a line list of World Health Organization confirmed cases, September 2006 to August 2010
L Fiebig ()1,2, J Soyka1,2, S Buda1, U Buchholz1, M Dehnert1, W Haas1
Robert Koch Institute, Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Berlin, Germany
These authors contributed equally to this article
Excerpt:
Case fatality
Fifty-six percent (132/235) of confirmed cases died. The CFR differed across countries ranging from 28% (27/98) in Egypt to 87% (71/82) in Indonesia. The cCFR and the 19-month rCFR indicated a decline in case fatality over the study period (Figure 1). Whereas the cCFR was little affected by the outcome of new cases and had only slightly decreased, the rCFR had steeply declined in the period from April 2008 to April 2009. Until mid 2008, a large proportion of cases occurred in Indonesia (country with highest CFR) and shifted thereafter to Egypt (country with lowest CFR). Accordingly, country-specific rCFRs for Indonesia and Egypt were less steep than the overall rCFR. The 19-months rCFR was privileged as it was less affected by case-free periods than rCFRs calculated over shorter periods (not shown).
In Egypt, fatal cases had a median age of 25 years, which was, at significant level, higher than the age of cases who survived (four years, p<0.001; Table 2). The CFR in Egypt was significantly higher in women than in men, (39% (22/56) vs 12% (5/42) respectively, p=0.003), which was not observed elsewhere (China: 63% (5/8) in women vs 70% (7/10) in men, p=1.0; Indonesia: 84% (43/51) vs 90% (28/31), p=0.521; Vietnam: 58% (7/12) vs 69% (9/13), p=0.688; remaining countries: 80% (4/5) vs 40% (2/5), p=0.524, respectively).
A significant difference in time from symptom onset to hospitalisation between survivors and fatal cases was only found in Egypt (one day vs four and a half days respectively, p=0.001, Table 3). All 19 cases worldwide hospitalised eight days after symptom onset or later had died.
Figure 3 shows the CFR in function of the time from symptom onset to hospitalisation, stratified by Egypt and Asian countries (grouped).
Figure 3. Time from confirmed avian influenza A(H5N1) human cases’ symptom onset to hospitalisation and case fatality rate stratified for Egypt and Asian countries, September 2006–August 2010 (n=197)
The median time from symptom onset to death was nine days (N=118), irrespective of the patients’ sex (p=0.605), and without significant difference across age groups (p=0.564, data not shown) or reporting countries (p=0.213).
The multivariable logistic regression revealed that odds of fatal outcome increased by 33% with each day that passed from symptom onset until hospitalisation (OR: 1.33, 95% CI: 1.11–1.60, p=0.002). In relation to children of 0–9 years, odds of fatal outcome were more than six times higher in 10–19 year-olds and 20–29 year-olds (OR: 6.06, 95% CI: 1.89–19.48, p=0.002 and OR: 6.16, 95% CI: 2.05–18.53, p=0.001, respectively), and nearly five times higher in patients of 30 years and older (OR: 4.71, 95% CI: 1.56–14.27, p=0.006).
Using Indonesia as a reference, odds of dying were lower elsewhere, namely by 92% in Egypt (OR: 0.08, 95% CI: 0.03–0.22, p<0.001), by 81% in China (OR: 0.19, 95% CI: 0.04–0.90, p=0.036), and by 79% in Vietnam (OR: 0.21, 95% CI: 0.06–0.75, p=0.016), but not in the grouped remaining countries (OR: 0.23, 95% CI: 0.04–1.27, p=0.091). Exposure to poultry was not significant and none of the interaction terms significantly improved the model fit. They were thus not retained in the final model.
Discussion and conclusions
With this study, we summarised the current global AI situation in humans. It is, to our knowledge, the first study that not only analysed human AI cases worldwide on the basis of a line list collected over several years but in addition made these case-based data available online. We found that a longer delay from symptom onset to hospital admission and belonging to older age groups were associated with higher mortality in AI patients, and that the situation in Egypt differed markedly from other countries with highest AI incidences in children and lowest CFR.
With our line list, cumulative case numbers published by WHO [4] could be largely reproduced: 235 of 256 WHO confirmed cases (92%) and additional 59 unconfirmed cases were captured between September 2006 and August 2010. The identified median reporting delay of 11 days after symptom onset may partly be explained by a deferred presentation to healthcare facilities as well as by the time needed for pathogen confirmation. About 52% of confirmed cases had been reported elsewhere in a median of three days prior to the WHO report. Because delays in availability of information could hamper investigations of the source of infection and of clusters of human cases [30], it could be beneficial to report and document probable cases in parallel with confirmed ones [31].
Confirmed cases had a median age of 18 years, which is consistent with earlier findings, although investigation periods and affected countries varied [2,19,21]. The identified predominance of female cases in Indonesia and Egypt and the low age median among Egyptian cases support findings from previous studies [2,23-25]. Schroedl [32] examined the mean age of cases in Egypt over four seasons between August 2006 and July 2009 and found a declining age-based pattern over time, but did not address sex-specific differences. We found, in line with other studies, a significantly older age of female cases than male cases, whose proportion had increased since 2008 in Egypt [24,25]. Chen et al., analysing AI cases worldwide before June 2006, also identified sex-specific differences in the age-groups of 4 to 6 years (95% male) and 25 to 30 years (83% female) [33]. They assumed particularly high levels of exposure in pre-school boys playing outdoors and housewives taking care of fowl and frequenting live markets. Fasina et al. suggested a similar explanation for the situation in Egypt [25].
Ninety-six percent of the cases had reportedly direct or indirect contact to potentially infected poultry, recognised as the most important risk factor for humans AI [8,34]. The WHO Clinical Case summary Form [35], where e.g. “poultry” can be checked as “most likely source of infection” has enhanced the systematic collection of information since 2007. However, currently reported information yields little insights into the actual source of infection and the intensity and quality of exposure needed to infect humans [36-38].
The median time from symptom onset to hospitalisation was four days, which is remarkably stable when compared to earlier studies [19,21]. If time to hospital admission is regarded as an indicator for monitoring case management and patients’ awareness [31], no progress would be evident from a global perspective so far.
The cases’ average CFR was 56%, which is widely consistent with findings from earlier investigation periods [2,19,23]. Using a 19-month rolling CFR, we found a clear decrease in case fatality, which persisted when stratifying for Egypt and Indonesia. It could thus not simply be explained by a predominance of Egyptian cases since 2009. Regarding the decreasing CFR in Egypt, Schroedl [32] suggested that the circulating AI virus strain may have become less virulent and more apt to spreading among children.
Analytical results revealed lowest odds of dying for Egyptian cases, even when adjusted for age, sex and time to hospitalisation. Thus, the high proportion of survivors in Egypt cannot be entirely explained – as often assumed – by sex-specific differences in CFR [21,24] and the high proportion of children among AI patients in Egypt [5], as well as short delays from symptom onset to hospitalisation [25].
It cannot be ruled out, that different virus clades circulating in Egypt (clade 2.2) and Asia (clades 2.1 and 2.3) shape the country-specific epidemiological features [2,23]. Differences in CFR across countries and changes over time might also partly be explained by differences in intensity and quality of exposure, health-seeking behaviour, reporting attitudes, overall performance of the surveillance system, and access to diagnostics and medical care [23,27,39,40], such as the time to start of oseltamivir treatment, the antiviral recommend by WHO for human infections with AI virus [2]. However, country-specific details on its administration are widely unknown and it remains controversial up to how many days after symptom onset the application of the antiviral reduces mortality [30,41]. In our study all patients hospitalised eight or more days after symptom onset died. This suggests a rather narrow time window for antiviral drug administration.
Our study was solely based on data from publicly available case reports and is subject to several limitations. Our monitoring instrument was only entirely implemented in August 2006 and thus trend analyses were not exploited to its full extent. Within the used reports, negative values, e.g. “case not hospitalised”, were not systematically mentioned, which may lead to biases. Time specifications, e.g. on dates of exposure or hospitalisation, needed for time-to-event analyses, were often incomplete. Case reports did not systematically contain details on medical care and specific antiviral treatment. Therefore, analyses were restricted to “hospitalisation” as general indicator for access to medical care. Given the sparse information on possible contact with infected individuals and clusters of human AI cases available from the serial reports within the investigated period, clusters could not be evaluated as initially planned. Other studies reporting on clustered cases had mostly accessed additional case-investigation reports and patient interviews [23,30]. We based our analyses on WHO confirmed cases, although unconfirmed cases had been recorded in our line list, due to lacking information for probable and suspected cases. Including probable cases in our analyses did, however, not change the cases’ sex ratio or CFR substantially when compared to confirmed cases only.
Our study points out that data extracted from the public domain already yields pertinent epidemiological information for assessing the current situation and developments of AI in humans. A line list format as provided would enhance the analysability of key data, their updating, and the evaluation of variables needed. Several countries monitor the global AI situation, whether they currently face human AI cases, e.g. Egypt [25], or not, e.g. France [27]. This indicates a common interest in data and if they were directly provided in such format, this would help to save time and resources for public health authorities and researchers.
A line list needs to be flexible in view of potential new information to be entered. New variables and parameter values might come up, when the minimum dataset suggested Bird and Farrar [31] on direct and indirect exposures to avian influenza A(H5N1) confirmed and non-confirmed poultry and human exposures would be implemented or when results from prospective studies involving exposed and unexposed individuals as designed by Kayali et al. [34] are available. Unconfirmed cases would ideally be recorded as systematically as confirmed cases, either in a common or separate database as suggested by Bird and Farrar [31].
Presenting cases in the format of a line list is not a goal in itself, but a prerequisite for targeting surveillance and identifying risk factors, as well as a starting point for prospective studies, e.g. investigating potential human-to-human transmission, the transmissibility of avian influenza viruses, and host-related factors including age-dependent immunity in humans [33,42].
We would like to encourage that an anonymised case-based database for AI in humans is directly placed publicly and continuously updated, e.g. by an internationally renowned organisation such as WHO. Open access to analysable data might accelerate the identification and implementation of research questions and surveillance priorities and thus enhance our understanding of – still mostly fatal – AI in humans and permit the rapid detection of epidemiological changes with implications for human health.
[Click on title for full document]
Research articles
Avian influenza A(H5N1) in humans: new insights from a line list of World Health Organization confirmed cases, September 2006 to August 2010
L Fiebig ()1,2, J Soyka1,2, S Buda1, U Buchholz1, M Dehnert1, W Haas1
Robert Koch Institute, Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Berlin, Germany
These authors contributed equally to this article
Excerpt:
Case fatality
Fifty-six percent (132/235) of confirmed cases died. The CFR differed across countries ranging from 28% (27/98) in Egypt to 87% (71/82) in Indonesia. The cCFR and the 19-month rCFR indicated a decline in case fatality over the study period (Figure 1). Whereas the cCFR was little affected by the outcome of new cases and had only slightly decreased, the rCFR had steeply declined in the period from April 2008 to April 2009. Until mid 2008, a large proportion of cases occurred in Indonesia (country with highest CFR) and shifted thereafter to Egypt (country with lowest CFR). Accordingly, country-specific rCFRs for Indonesia and Egypt were less steep than the overall rCFR. The 19-months rCFR was privileged as it was less affected by case-free periods than rCFRs calculated over shorter periods (not shown).
In Egypt, fatal cases had a median age of 25 years, which was, at significant level, higher than the age of cases who survived (four years, p<0.001; Table 2). The CFR in Egypt was significantly higher in women than in men, (39% (22/56) vs 12% (5/42) respectively, p=0.003), which was not observed elsewhere (China: 63% (5/8) in women vs 70% (7/10) in men, p=1.0; Indonesia: 84% (43/51) vs 90% (28/31), p=0.521; Vietnam: 58% (7/12) vs 69% (9/13), p=0.688; remaining countries: 80% (4/5) vs 40% (2/5), p=0.524, respectively).
A significant difference in time from symptom onset to hospitalisation between survivors and fatal cases was only found in Egypt (one day vs four and a half days respectively, p=0.001, Table 3). All 19 cases worldwide hospitalised eight days after symptom onset or later had died.
Figure 3 shows the CFR in function of the time from symptom onset to hospitalisation, stratified by Egypt and Asian countries (grouped).
Figure 3. Time from confirmed avian influenza A(H5N1) human cases’ symptom onset to hospitalisation and case fatality rate stratified for Egypt and Asian countries, September 2006–August 2010 (n=197)
The median time from symptom onset to death was nine days (N=118), irrespective of the patients’ sex (p=0.605), and without significant difference across age groups (p=0.564, data not shown) or reporting countries (p=0.213).
The multivariable logistic regression revealed that odds of fatal outcome increased by 33% with each day that passed from symptom onset until hospitalisation (OR: 1.33, 95% CI: 1.11–1.60, p=0.002). In relation to children of 0–9 years, odds of fatal outcome were more than six times higher in 10–19 year-olds and 20–29 year-olds (OR: 6.06, 95% CI: 1.89–19.48, p=0.002 and OR: 6.16, 95% CI: 2.05–18.53, p=0.001, respectively), and nearly five times higher in patients of 30 years and older (OR: 4.71, 95% CI: 1.56–14.27, p=0.006).
Using Indonesia as a reference, odds of dying were lower elsewhere, namely by 92% in Egypt (OR: 0.08, 95% CI: 0.03–0.22, p<0.001), by 81% in China (OR: 0.19, 95% CI: 0.04–0.90, p=0.036), and by 79% in Vietnam (OR: 0.21, 95% CI: 0.06–0.75, p=0.016), but not in the grouped remaining countries (OR: 0.23, 95% CI: 0.04–1.27, p=0.091). Exposure to poultry was not significant and none of the interaction terms significantly improved the model fit. They were thus not retained in the final model.
Discussion and conclusions
With this study, we summarised the current global AI situation in humans. It is, to our knowledge, the first study that not only analysed human AI cases worldwide on the basis of a line list collected over several years but in addition made these case-based data available online. We found that a longer delay from symptom onset to hospital admission and belonging to older age groups were associated with higher mortality in AI patients, and that the situation in Egypt differed markedly from other countries with highest AI incidences in children and lowest CFR.
With our line list, cumulative case numbers published by WHO [4] could be largely reproduced: 235 of 256 WHO confirmed cases (92%) and additional 59 unconfirmed cases were captured between September 2006 and August 2010. The identified median reporting delay of 11 days after symptom onset may partly be explained by a deferred presentation to healthcare facilities as well as by the time needed for pathogen confirmation. About 52% of confirmed cases had been reported elsewhere in a median of three days prior to the WHO report. Because delays in availability of information could hamper investigations of the source of infection and of clusters of human cases [30], it could be beneficial to report and document probable cases in parallel with confirmed ones [31].
Confirmed cases had a median age of 18 years, which is consistent with earlier findings, although investigation periods and affected countries varied [2,19,21]. The identified predominance of female cases in Indonesia and Egypt and the low age median among Egyptian cases support findings from previous studies [2,23-25]. Schroedl [32] examined the mean age of cases in Egypt over four seasons between August 2006 and July 2009 and found a declining age-based pattern over time, but did not address sex-specific differences. We found, in line with other studies, a significantly older age of female cases than male cases, whose proportion had increased since 2008 in Egypt [24,25]. Chen et al., analysing AI cases worldwide before June 2006, also identified sex-specific differences in the age-groups of 4 to 6 years (95% male) and 25 to 30 years (83% female) [33]. They assumed particularly high levels of exposure in pre-school boys playing outdoors and housewives taking care of fowl and frequenting live markets. Fasina et al. suggested a similar explanation for the situation in Egypt [25].
Ninety-six percent of the cases had reportedly direct or indirect contact to potentially infected poultry, recognised as the most important risk factor for humans AI [8,34]. The WHO Clinical Case summary Form [35], where e.g. “poultry” can be checked as “most likely source of infection” has enhanced the systematic collection of information since 2007. However, currently reported information yields little insights into the actual source of infection and the intensity and quality of exposure needed to infect humans [36-38].
The median time from symptom onset to hospitalisation was four days, which is remarkably stable when compared to earlier studies [19,21]. If time to hospital admission is regarded as an indicator for monitoring case management and patients’ awareness [31], no progress would be evident from a global perspective so far.
The cases’ average CFR was 56%, which is widely consistent with findings from earlier investigation periods [2,19,23]. Using a 19-month rolling CFR, we found a clear decrease in case fatality, which persisted when stratifying for Egypt and Indonesia. It could thus not simply be explained by a predominance of Egyptian cases since 2009. Regarding the decreasing CFR in Egypt, Schroedl [32] suggested that the circulating AI virus strain may have become less virulent and more apt to spreading among children.
Analytical results revealed lowest odds of dying for Egyptian cases, even when adjusted for age, sex and time to hospitalisation. Thus, the high proportion of survivors in Egypt cannot be entirely explained – as often assumed – by sex-specific differences in CFR [21,24] and the high proportion of children among AI patients in Egypt [5], as well as short delays from symptom onset to hospitalisation [25].
It cannot be ruled out, that different virus clades circulating in Egypt (clade 2.2) and Asia (clades 2.1 and 2.3) shape the country-specific epidemiological features [2,23]. Differences in CFR across countries and changes over time might also partly be explained by differences in intensity and quality of exposure, health-seeking behaviour, reporting attitudes, overall performance of the surveillance system, and access to diagnostics and medical care [23,27,39,40], such as the time to start of oseltamivir treatment, the antiviral recommend by WHO for human infections with AI virus [2]. However, country-specific details on its administration are widely unknown and it remains controversial up to how many days after symptom onset the application of the antiviral reduces mortality [30,41]. In our study all patients hospitalised eight or more days after symptom onset died. This suggests a rather narrow time window for antiviral drug administration.
Our study was solely based on data from publicly available case reports and is subject to several limitations. Our monitoring instrument was only entirely implemented in August 2006 and thus trend analyses were not exploited to its full extent. Within the used reports, negative values, e.g. “case not hospitalised”, were not systematically mentioned, which may lead to biases. Time specifications, e.g. on dates of exposure or hospitalisation, needed for time-to-event analyses, were often incomplete. Case reports did not systematically contain details on medical care and specific antiviral treatment. Therefore, analyses were restricted to “hospitalisation” as general indicator for access to medical care. Given the sparse information on possible contact with infected individuals and clusters of human AI cases available from the serial reports within the investigated period, clusters could not be evaluated as initially planned. Other studies reporting on clustered cases had mostly accessed additional case-investigation reports and patient interviews [23,30]. We based our analyses on WHO confirmed cases, although unconfirmed cases had been recorded in our line list, due to lacking information for probable and suspected cases. Including probable cases in our analyses did, however, not change the cases’ sex ratio or CFR substantially when compared to confirmed cases only.
Our study points out that data extracted from the public domain already yields pertinent epidemiological information for assessing the current situation and developments of AI in humans. A line list format as provided would enhance the analysability of key data, their updating, and the evaluation of variables needed. Several countries monitor the global AI situation, whether they currently face human AI cases, e.g. Egypt [25], or not, e.g. France [27]. This indicates a common interest in data and if they were directly provided in such format, this would help to save time and resources for public health authorities and researchers.
A line list needs to be flexible in view of potential new information to be entered. New variables and parameter values might come up, when the minimum dataset suggested Bird and Farrar [31] on direct and indirect exposures to avian influenza A(H5N1) confirmed and non-confirmed poultry and human exposures would be implemented or when results from prospective studies involving exposed and unexposed individuals as designed by Kayali et al. [34] are available. Unconfirmed cases would ideally be recorded as systematically as confirmed cases, either in a common or separate database as suggested by Bird and Farrar [31].
Presenting cases in the format of a line list is not a goal in itself, but a prerequisite for targeting surveillance and identifying risk factors, as well as a starting point for prospective studies, e.g. investigating potential human-to-human transmission, the transmissibility of avian influenza viruses, and host-related factors including age-dependent immunity in humans [33,42].
We would like to encourage that an anonymised case-based database for AI in humans is directly placed publicly and continuously updated, e.g. by an internationally renowned organisation such as WHO. Open access to analysable data might accelerate the identification and implementation of research questions and surveillance priorities and thus enhance our understanding of – still mostly fatal – AI in humans and permit the rapid detection of epidemiological changes with implications for human health.
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Sunday, August 14, 2011
Vinh Long: Destruction of 2,500 chickens have bird flu.
According to the provincial Veterinary Bureau, has worked with local organizations and destruction of 2,500 chickens was avian households in two communes of Hoi Chanh (Mang Thit district). From this year, the province has nearly 20,000 chickens have bird flu treatment destroyed. However, avian influenza vaccination for chickens phase I/2011 was only 40.8% of the plan (flock reaches 116% of plan).
UAE intensifies efforts to contain cholera in Somalia
15 August 2011
MOGADISHU - As an outbreak of cholera threatened tens of thousands of people fleeing the famine-hit areas of Somalia to pack into the crowded camps in the country’s capital, Mogadishu, the UAE fortified its medical efforts to contain the spread of the epidemic.
UAE’s mobile hospital continued to provide its ambulatory and medical services to the patients in the makeshift camps in and around the capital.
The Emirati mobile hospital has been welcomed as a great humanitarian service by the people in the region and is a worthy addition to the achievements in the vital initiatives of this kind.
The single hospital in Mogadishu is virtually helpless to cope up with the increasing number of patients being brought into it. According to the UN World Health Organisation, several people have died from suspected cholera cases in the hospital in Mogadishu, and there have been many other confirmed cholera outbreaks across the country.
Since the mobile hospital was inaugurated last week, it has visited the refugee camp in the suburbs of Mogadishu to give treatment to more than 820 patients suspected to be suffering from Cholera.
Cholera is caused by a bacteria that infects the small intestine and is spread through dirty water.
It is easily treated with oral rehydration salts and antibiotics. But many health centres in Somalia lack even these basic supplies. As a result, those who get cholera, especially children, can die of dehydration within days or even hours of being infected.
Since day one of its opening, the mobile hospital continues to receive increasing number of patients, many of whom are women and children.
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