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H5N1 Confirmation Delays in Egypt Raise Concerns
Recombinomics Commentary 13:04
April 6, 2009

A 6-year-old Egyptian boy has contracted the highly pathogenic bird flu virus, the sixth case in a month in the most populous Arab country, state news agency MENA said on Sunday.

MENA named the boy as Ali Mahmoud Ali Somaa, from the Nile Delta province of Qalyubia.

Health Ministry spokesman Abdel Rahman Shahine said Somaa started suffering symptoms two weeks ago and was admitted to hospital a week later, where he was treated with the antiviral drug tamiflu, according to MENA.

Somaa is in a critical condition and is breathing with an artificial respirator,

The above comments describe the latest confirmed case (6M) in Egypt (#63 since 2006).  Unlike the vast majority of cases in 2009, who are toddlers with mild courses, the latest case is in critical condition and on a respirator (see updated map).  Only one other case in 2009 was described as critical, and since that case was hospitalized March, 1, the patient has probably recovered, because all 12 confirmed cases this year have survived.

The severity of the above case may be associated with the delay in hospitalization and the delay in diagnosis.  These delays may be linked to an absence of a poultry connection.  Over 6000 Egyptians have been  hospitalized with suspected bird flu, but less than 1% test positive for H5N1.  However, these cases begin treatment shortly after admission, based on symptoms and a poultry connection.  The above case developed symptoms on March 22 and was hospitalized on March 28, but was reported confirmed yesterday, which was well after confirmation of case 61 who was hospitalized on March 31, and case 62, who was hospitalized on April 2.  The delay in confirmation of case 63 is likely linked to a delay in testing and treatment.  Since descriptions of case 63 have not mentioned a poultry source, it is likely that the lack of a source contributed to the admission and treatment delays.

However, these delays raise concerns that many milder cases would go untreated and/or unreported, because of resolution in the absence of treatment, or treatment based on an assumption of seasonal flu.  Since patients without poultry links are not tested for H5N1, recovery of such patients would lead to a serious undercount of H5N1 infections.  Moreover, a lack of such testing would also lead to a serious undercount of clusters, such as cases 61 and 62.

These two cases are toddlers from Beheira who were confirmed this month.  They are next door neighbors, but case 61 was diagnosed in Menoufiya, where he developed symptoms and was hospitalized.  Case 61 had a poultry connection, but it remains unclear if that connection was in Beheira, or in association with his visit to grandparents in Menoufiya.  Case 62 was confirmed a few days after case 61, but no poultry connection was described for case 62, suggesting an absence of poultry deaths in the Beheira neighborhood where cases 61 and 62 lived.

This type of detail and associations are usually clarified in WHO updates, which are lagging cases.  The last WHO update was on patient 60, who was confirmed last month.  Moreover, there is also confusion regarding a 45 day old infant who died March 27 after being hospitalized March 26.  Although samples were collected from the patient and family, and Tamiflu was given, the test results on this patient have not been announced, even though hospitalization and death were prior to confirmed cases 61-63. 

The delays in clarification of these cases are causes for concern.  Similarly, sequences from poultry and human cases in 2009 have not been released. 

Clarifications and release of sequences would be useful.

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