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First H5N1 Case In Iraq Confirmed by Clinical Presentation

Recombinomics Commentary

January 20, 2006

According to doctors in Sulaimaniyah, the symptoms were exactly like those seen in victims in neighbouring Turkey, where 22 people this month have been confirmed as having the virus.

"She was a perfect victim of bird flu," noted Dr Sardar Abbas, a clinician at the hospital. "We just need the final results of her samples to confirm it."

The above comments indicate the first report cases of H5N1 in Iraq has been identified.  Unfortunately. lab confirmation of cases has been poor since H5N1 was first identified in humans in Vietnam in early 2004.  The poor testing is easily seen in clusters, because the negatives are clearly false.  This is most obvious in initial cases in a country, because countries are reluctant to confirm H5N1 initial cases.

The exclusion of clear H5N1 from WHO's confirmed list has been firmly in place since early 2004 and has been applied to all countries reporting H5N1.  An early cluster in Vietnam involved a groom and his two sisters who cared fro him. The index developed a fatal H5N1 infection but was never tested.  His sisters developed symptoms on the same, were admitted to the hospital the same, initially tested inclusive, subsequently tested H5N1 positive and died within 1 hour of each other.  Since the index was not tested and the two family members initially were inconclusive, positive results may not have been recorded had not the cases formed a cluster.

In Thailand a similar situation developed with a girl staying with her aunt.  The index case developed symptoms after burying her pet bird.  The index case was diagnosis as dengue fever because she was bleeding from the gums.  Her mother, who worked hundreds of miles away in a Bangkok office visited her daughter in the hospital.  Because of the Dengue misdiagnosis, the mother was allowed to hold her daughter.  After her daughter dies, the mother developed symptoms and died in Bangkok, she also was not tested.  However, a nurse notified investigators who found the mother just prior to cremation. They collect tissue, which was positive.  The aunt also developed symptoms.  After initially testing negative the aunt testes positive and survived.

In Cambodia the first reported case died after collecting dead chickens in the village.  After he died his sister developed symptoms. After seeing a local doctor she was rushed to Ho Chi Minh City, where she died.  However, she tested positive for H5N1, so she was considered the first H5N1 patient in Cambodia, although her brother died first.

The pattern was repeated in Indonesia.  The index case was not tested initially.  Her sister also became infected as did her father.  However, only the father is confirmed as positive.  The index case had high titer antibody in two samples, but they were collected three days apart and the high titer did not go up fold fold over the first collection.

In China the initial case was also a cluster.  The oldest child developed symptoms and died. The younger  sibling eventually tested positive.

In Turkey the first four siblings all tested negative initially. The three fatal cases tested positive, but the youngest family member was discharge and is still negative, although he has symptoms.

Thus, the large number of false negatives makes the clinical diagnosis in Iraq more credible than lab tests with a history of false negatives.

WHO's position of using the false negatives to exclude H5N1 infected patients has limited the number of cases and clusters, but the clinical picture leaves little doubt that the H5N1 case in Iraq is infected and represents the first reported case in Iraq. 

However, the explosion of H5N1 bird and human cases in Turkey leaves little doubt that addition H5N1 infections exist in countries neighboring Turkey, such as Iraq.


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