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H5N1 False Negatives in the Middle East

Recombinomics Commentary

January 30, 2006

"As this has occurred in a region next to a country identified with a H5N1 outbreak, it would not be surprising" that it has shown up in Iraq, WHO spokeswoman Maria Cheng said.

Although the above comment by WHO is true this week, it also was true last week when WHO “discounted” the report that the index case in Iraq had died from bird  flu.  Media quotes from the physician at the scene indicated the girl had symptoms that matched the fatal cases in Turkey.  The large number of confirmed H5N1 cases in birds and humans in Turkey left little doubt that neighboring countries, including Iraq, were reporting false negative reports.  WHO now says the basis of the discount was the false negative in Iraq. 

However, as WHO knows, every new outbreak in a new country has had at least one false negative.  The initial reported cases in Cambodia, Indonesia, China, and Turkey all were clusters with likely human-to-human transmission which included untested or false negative cases that were excluded by WHO, which eliminated the record of the cluster and the human-to-human transmission. 

In Cambodia the index case died.  His sister developed symptoms and tested positive after she died in Vietnam.  WHO excluded the index case because samples were not collected.

In Indonesia the index case was diagnosed with bacterial pneumonia.  After her sister and father were hospitalized the father tested positive for H5N1.  All three family members died, but the younger sister was excluded because samples were not collected and the index case was excluded because the difference in titer between her two strongly positive serum samples was not a four fold difference.

In China two siblings developed bird flu symptoms after an outbreak in their village.  The index case died, but was excluded because samples were not collect.  The sibling was H5N1 positive.

In Turkey all four siblings initially tested negative.  Three siblings died and were H5N1 confirmed, but the fourth sibling was excluded because of a false negative test.  The fourth sibling still has not been retested to show that he was H5N1 positive.

All of the above clusters had a time gap between disease onset dates of the index case abd other family members.  However, WHO exclusions eliminated clusters in all countries except Turkey.  However, in Turkey WHO eliminated the disease onset date.

WHO’s omissions in Turkey were quite remarkable.  Normally, WHO updates on H5N1 positive patients include disease onset dates as well as information on relatives.  This information was glaringly absent in updates in Turkey.

WHO officials were well aware of the fact that the initial cases in Turkey were largely composed of relatives. Officials were quoted in media reports shortly after the oldest Kocyigit sibling died and they indicated that two large families were involved.  The two large families were Kocyigit and Ozcan, but WHO failed to indicate that the two large families were related to each other.

When WHO published updates on the deaths of the three oldest Kocyigit siblings, they failed to mention that 10 Ozcan cousins were in the same hospital and two were H5N1 positive.  They also failed to give disease onset dates for the Kocyigit siblings.

When the two Ozcan cousins were described in WHO updates disease onset dates were not given, nor were the 8 family members hospitalized in the same hospital mentioned.  The relationship of the positive Ozcans to the deceased Kocyigts was also not give,

Similarly, when a second set of Ozcan cousins were admitted and tested positive there was no mention of relationships to the deceased Kocyigits or the H5N1 positive or hospitalized Ozcans, even though the update indicated no additional family member had symptoms.

Thus, after the above commissions by omission, WHO “discounted” the now confirmed H5N1 index case in Iraq.  These misrepresentations encourage neighboring countries to misrepresent the H5N1 situation.  No country in the Middle East has filed an OIE report on H5N1 in poultry and the index case in Iraq is the only reported human H5N1 case in the Middle East

The false negatives on H5N1 in people and birds in Europe, the Middle East, and Africa are predictable, as is WHO’s inability to convince countries to transparently report H5N1 infections.


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