Egypt, Azerbaijan and the task ahead

Egypt and Azerbaijan are both reporting more human cases of bird flu. First, Egypt. There are now a total of four cases, one fatal, all with histories of contact with sick poultry. Three more people are suspect cases and under observation. Poultry infection is now widespread in the country, affecting 18 of 26 provinces. While Egypt lies along migratory bird flyways, it is likely that spread in the country is from the movement of poultry or people contaminated with poultry products.

The situation in Azerbaijan is similar, although a relatively large cluster of four related people is cause for some concern (apologies to Henry Niman for using his trademarked phrase). WHO issued an update today, saying that as of ten days ago 7 of 11 cases were confirmed as H5N1, five fatal. WHO anticipates an official Azerbaijan government statement "shortly." Six of the seven cases are in Daikyand settlement (800 homes) in Salyan province in the southeast.

A 17-year-old girl died on 23 Feb 2006. Her first cousin, a 20-year-old woman, died on 3 Mar. The 16-year-old brother of this woman died on 10 Mar. A 17-year-old girl, a close friend of the family, died on 8 Mar. All 4 of these cases lived together or near each other. The source of their infection is presently under investigation.

The additional 2 cases in Salyan involve a 10-year-old boy, who has recovered, and a 15-year-old girl, who is hospitalized in critical condition.

The 7th case occurred in a 21-year-old woman from the western rayon of Tarter. She died on 9 Mar 2006.

thus we have six cases in the same province, four of them related or in contact with each other. The dates of onset are not given, only dates of death, so it is not possible from this information to judge whether person-to-person transmission is plausible.

The WHO update speculates on a possible scenario for these infections in Salyansk, citing "some evidence" of a swan die-off some weeks ago where the carcasses were left unburied.

In this community, the defeathering of birds is a task usually undertaken by adolescent girls and young women. The WHO team is today investigating whether this practice may have been the source of infection in Daikyand, where the majority of cases have occurred in females between the ages of 15 and 20 years. Interviews with surviving family members have failed to uncover a history of direct exposure to dead or diseased poultry for several of the cases.

The update mentions two additional suspect cases in an adjacent province, but Mosnews is reporting that WHO now has 14 suspect cases under investigation. The suspect cases may be the product of an ongoing house to house surveillance effort for influenza like illness (ILI) being done by local medical teams. A US Naval Medical Research Unit (NAMRU3) is providing laboratory support.

What does this all mean? Influenza A/H5N1 continues to infect poultry over a widespread area of the globe. In nine countries where poultry infection exists there have also been human cases (China, Vietnam, Cambodia, Thailand, Indonesia, Turkey, Iraq, Egypt, Azerbaijan). Thus this virus in its various forms is capable of crossing bird and mammalian species barriers. It is also changing genetically. So far its clinical forms have been strikingly virulent.

Many uncertainties remain because we don't understand the biology of this virus well enough to make accurate predictions. At this point, however, the H5N1 subtype is the top candidate for the next serious pandemic influenza virus. Not a day passes that this doesn't become more likely.

None of the news is reassuring. None. It is time to take a deep breath, roll up our sleeves and calmly but with serous purpose methodically and systematically set about the task of getting ready for a period of widespread community illness that will tax our resources, our patience and our ingenuity. Every community has done it before and we can do it this time. While we prepare to look after ourselves and our families, we will all fare much better if we also put significant effort into how we can help each other. You might as easily be the one who needs help as the one able to give it. And that received help might be the difference between you or a loved one's life or death.

The best outcome will be if this pandemic never materializes. This is possible, although seeming less likely by the day. The advantage of strengthening community relationships and structures that foster mutual aid in prepration is that it will not be wasted. We get better, stronger, more resilient communities for whatever happens.

There is still time to fill the sandbags and get our treasures up off the floor. We can help each other. Let's get busy.