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Fifth H5N1 Patient in Egypt Dies
Recombinomics Commentary
January 19, 2007

Warda Eid Ahmed, 27, from Beni Suef province, south of Cairo, was transferred to hospital in the capital on Jan. 13 suffering from pneumonia.

A Health Ministry spokesman said earlier in the week she had raised hens in her house. The ministry has dispatched a team to take samples from the rest of her family, he said.

MENA quoted Health Ministry spokesman Abdel Rahim Shahin on Friday as saying said she was the 11th person in Egypt to die from bird flu out of 19 human cases.

The above comments describe the death of the most recent confirmed case in Egypt.  This season there have been five confirmed cases, and all five have died.  This 100% case fatality rate for the 2006/2007 season is in marked contrast to the rate in the spring of 2006, when 6 of the 14 cases died.

The HA sequences of three of the recent cases have been released.  Although these recent sequences had many of the regional markers seen in the spring, several new sequences appeared.  The three sequences all had M230I, which is adjacent to the receptor binding domain.  M230I is present in all three human influenza's, H1N1, H3N2, and influenza B.  Moreover, the change creates a five amino acid match between positions 226-230 in the influenza B receptor binding domain.  In addition, the two sequences from the Gharbiya cluster have an additional change in the receptor binding domain, V223I, which is in a Qinghai bar headed goose isolate from Mongolia as well as Shantou duck isolates in China.  The acquisition of these new polymorphisms is cause for concern.

In addition, the two members of the Gharbiya cluster have acquired NA`N294S, which is linked to Tamiflu resistance.  This change was in both patients in samples collected two days after treatment.  The sequences were directly from the samples and had no evidence of wild type H5N1, or H5N1 with H274Y, the common Tamiflu resistance change. Prior to the Gharbiya cluster, all patients with Tamiflu resistance had H274Y, including the case (14F) in Vietnam who also had N294S.  The absence of H274H or wild type H5N1 coupled with the detection of N294S in ducks, strongly suggests the N294S in the Gharbiya cluster was not due to Tamiflu treatment.

The first four fatalities from this season were from Gharbiya.  The latest fatality is from Beni Suef, over 150 miles south of Gharbiya, which has led to the generation of novel HA and NA sequences.  Thus, although all five patients in Egypt have died, the H5N1 in the region has significant heterogeneity, highlighting the need for widespread testing in the region to determine the distribution of NA N294S, as well as the increasing diversity of Qinghai H5N1 in the region.

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