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H5N1 Human Cluster in Iraq
January 31, 2006
"We have 12 patients in Sulaimaniya that have lung infections that we suspect may be the bird flu virus," Kurdistan's deputy prime minister, Imad Ahmed, told Reuters, referring to one of the region's largest cities.
The most serious was 54-year-old Mariam Qader, who came from the same village as the dead girl and is believed to be a distant relative of the victim.
The above comments raise additional concerns of human-to-human transmission in Iraq. The index case (15F) died on January 17, 2006. Here uncle (39M), who lived in the same house and cared for her developed symptoms on January 24 and died January 27. The distant relative (54F), who lived in the same village, was hospitalized in January 18. Bird contacts for the 54F have not been mentioned and media reports for the disease onset date for the index case have been conflicting. The WHO report of Iraq does not give a disease onset date for the index case. The report also does not indicate that the 54F is related to the two fatal cases.
The omission of these details is cause for concern. Extensive omissions were present in the Turkey H5N1 updates. The disease onset dates for the index case or relatives was not given. The relationship between the index case and two sets of cousins who subsequently were H5N1 positive also was not given. The glaring omissions reduce credibility.
The H5N1 isolated from the index case in Turkey had the HA polymorphism S227N (also called S223N). This change increases the affinity of HA for human receptors in the respiratory tract and was a likely contributor to the generation of large clusters and human-to-human transmission in Turkey. The current cluster in Iraq may also be linked to this genetic change, and withholding disease onset dates and relationships between suspect patients creates unnecessary confusion.
The WHO has indicated that they do not see evidence for sustain human-to-human transmission in Turkey or Iraq. However, previous comments indicate a lack of evidence for easy human-to-human transmission.
Although the changing terminology points toward more efficient human-to-human transmission of H5N1 in the Middle East, the WHO updates of late tend to obscure this important fact.