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H5N1 Confirmed in Cyprus

Recombinomics Commentary

January 29, 2006

The European Commission said Sunday that tests conducted in a British laboratory on samples from birds in northern Cyprus had revealed they had died of the deadly H5N1 strain of the virus.
The same strain has killed four people in Turkey and infected at least 21 others.

Two suspected bird flu cases were found in poultry in the Turkish Cypriot north of the island last week, leading authorities in the Greek Cypriot south _ part of the European Union _ to disinfect vehicles from the north and keep poultry indoors.

"No live animals or animal products, including all poultry products and feathers, can be transferred across the Green Line or to the European Union," the EU executive said, adding that two EU experts would leave for the area to investigate the situation.

The above comments suggests the lapses in H5N1 surveillance in Europe, the Middle east, and Africa have been and continue to be serious.  H5N1 was first detected in western Turkey in October, 2005.  Although there were significant poultry and wild bird die offs in eastern Turkey at the time, H5N1 involvement was denied.  However, after the H5N1 human cases were confirmed in early 2006, new OIE reports were filed by Turkey which indicated H5N1 infections in Turkey had been detected in mid-November.  More recent OIE reports indicated that there has been an explosion of H5N1 outbreaks in wild birds and domestic poultry in Turkey and these outbreaks have been widespread and included border provinces.

The OIE reports suggest H5N1 has been in Turkey since October and migration of birds through Turkey in the past several months would have spread H5N1 to adjacent countries in Europe and the Middle East and further migration would have moved H5N1 into Africa.  However, none of these neighboring countries have filed OIE reports on H5N1 outbreaks.

Recent inspections by the EU, US, and WHO authorities in adjacent countries has raised the level of concern higher,  The adjacent countries have conducted extensive culls in border regions, but have yet to acknowledge any H5N1 infections.  New WHO regulations beginning in January 2006 allow neighboring countries to express concerns over unreported illness that can cross international borders, yet there are still no H5N1 in countries that clearly have H5N1 infections.

The lack of filing of reports of H5N1 in birds has also led to a lack of reports of H5N1 infections in humans. In Turkey, the first four suspected bird flu cases were initially said to be negative, yet the three fatal cases subsequently tested positive for H5N1.  However, the fourth sibling is still not a confirmed case and has been excluded fro the WHO list of confirmed H5N1 cases.

This exclusion extends the WHO record on initial reports of H5N1 in humans in a country that had not previously reported infections.  Each instance involves a familial cluster involving at least one fatality and at least one exclusion.  In Cambodia the index case was excluded because samples were not collected.  His sister subsequently developed symptoms and was diagnosed as H5N1 positive after she died in neighboring Vietnam.  In Indonesia the index case was excluded because the two serum samples which were H5N1 positive were collected three days apart so the titer of the second collection was not four fold higher than the first.  The sister was excluded because proper samples were not collected and only the father was classified as a confirmed case.  In China the index case was also excluded because proper samples were not collected.  Her brother survived and eventually tested  positive for H5N1.

In Turkey, only the youngest sibling was excluded.  The three older fatal cases were included, but the update describing the patients failed to include disease onset dates.  In each of the prior clusters above, there was a gap between the index case and family members, but exclusion of the family members eliminated the cluster.  In Turkey, the missing information on onset dates was followed by additional cases where associated data was glaringly absent.  Two cousins of the index cases were H5N1 confirmed, but the update on the two cousins failed to give disease onset date and relationship to the earlier cases.  Moreover, eight additional family members were hospitalized and the update did not reveal that information.  When the third set of cousins was H5N1 confirmed, that update also failed to confirm the relationship with the earlier sets of cousins and the update indicated that additional family members did not show symptoms.  However, 3 cousins were H5N1 and dead, while two more were H5N1 positive and hospitalized, while 9 others had been hospitalized.

Thus lack of transparency was extended when a bird flu suspect in Iraq died.  WHO “discounted” the case, but reasons for the discount were not given.  The physician in Iraq indicated the symptoms matched those of fatal cases in Turkey, and the fatal case had contact with domestic birds and lived near migratory birds.  Now the uncle of the index case has also died with the same symptoms, suggesting he was infected by his niece.  Now WHO is sending samples to Weybridge for testing and if confirmed, the prior requirements for a new H5N1 case in a new country would have been extended.  One family member has been excluded by WHO, one or more has died, and the cluster represents the first reported cases.

Although the Z genotype of H5N1 has been reported in humans since earlier 2004, the same lack of reporting and testing has been repeated in Turkey and probably Iraq.  Thus, the monitoring and reporting of H5N1 in birds and people remain scandalously poor.


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