Friday, July 29, 2005

Vietnam, Indonesia, Russia, China

Four geographic areas seem to be "cause for concern" on the bird flu front, (as Henry Niman would say). They are Vietnam, Indonesia, Russia and China.

Vietnam (Thanhnien News): This is the easiest, although not necessarily the least concerning (I'm having trouble ranking different kinds of concerns, so I won't try). It's easiest because it represents "more of the same," where the "same" is not good. Two more H5N1 deaths have been reported, a 24 year old man from Tra Vinh (Mekong region, in the south) and a 26 year old woman from Ho Chi Minh City (also in the south). Both are confirmed bird flu cases, the first in the south for some time. The southern cases continue to be more serious than those from the north. Both cases were said to have eaten chicken before they became ill. So this disease, possibly in several different forms (north and south) continues to incubate and simmer in Vietnam, with endemic infection of poultry and sporadic but fairly steady human cases. Such smoldering is typical of pre-pandemic phases which then break out explosively. But of course, sometimes this doesn't happen. I'm not a betting person, so I prefer to purchase insurance for uncertain events in the form of adequate preparation. Are you listening CDC?

Indonesia: The reference laboratory in Hong Kong has confirmed what everyone knew anyway, that the index case in the family cluster of three fatal cases in a Jakarta suburb, the eight year old daughter, indeed died of H5N1. Tests results on her 1-year old sister are awaited but we know the answer already. Meanwhile, epidemiologic investigations seem to be coming up empty. How did this civil servant and his two children in a middle class suburb contract this fatal disease? We are learning some more details about the basis for the claim by the Indonesian Health Minister that they were infected by contaminated bird feces (the Chickenshit Theory). The Minister of Agriculture reported that feces from a caged bird on the side of the road opposite the family's house were "positive for H5N1" but the bird in the cage showed no sign of the virus and other environmental sampling, including caged birds in neighbor's houses. So much for the Chickenshit Theory.

The three family members fell ill on July 24, July 29 and July 2, so this doesn't sound like a common source outbreak but more like person to person (perhaps index case to other two family members). Indonesian authorities are following up some 300 contacts of the family, but have so far reported no additional illnesses. Forty-four referral hospitals have been alerted and prepared for possible new cases. So at the moment there is no identified source for the three fatal cases and the evidence of human to human transmission is strong.

Russia: The bird flu outbreaks in Russia have been widely reported to be with H5N2 and therefore no risk to humans. Aside from the fact that it doesn't necessarily follow that H5N2 infections of birds are no risk to humans, the point is now moot, as fresh outbreaks are being identified as H5N1. Today the Russian Agriculture Ministry announced that the hundreds of chicken, geese, ducks and turkeys that died in Siberia last week died of H5N1 infection. This virus is on the wing, literally and figuratively, and it can't be stopped. It seems it will inevitably spread to bird populations outside of Asia, with the next stop likely the Indian sub-continent and Europe. The longer it circulates in birds and perhaps other species, the more likely it will be to adapt to humans, the most widely dispersed species on earth.

China: Finally, the spreading outbreak in Sichuan, China. The Chinese have steadfastly maintained that this is just a huge outbreak from the bacterium Streptococcus suis, Type 2, a known pig pathogen that occasionally infects humans, causing meningitis. While it is capable of causing the type of sepsis presenting in these cases, the large number and continued spread together with the hemorrhagic presentation seems quite atypical for S. suis and more like a viral etiology. There are now over 150 infections with new ones occurring daily. The death toll stands at 51 as of Thursday afternoon. While bird flu remains a possibility (we are continually reminded that a significant proportion of cases in 1918 presented like this) there is no mention of respiratory symptoms which should still predominate. This one remains a puzzle, and while the pig bacteria may turn out to be the cause, it sounds at this point like something else is going on (although my intuiution tells me it isn't bird flu, but of course I may be wrong).

But with so much else going on elsewhere, "something else going on in China" is the last thing I want to hear.