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Lack of Confirmed H5N1 Poultry Linkage To  Egyptian Cases
Recombinomics Commentary 21:09
April 6, 2009

Date of report: 5 April 2009
Governorate: Qalioubiya
District: Shoubra el Kheima
Event summary: Boy, age 6, began experiencing symptoms March 22. He was admitted to Ain Shams University hospital March 28 and received Tamiflu on April 3. Infection with avian influenza was confirmed April 5. He was reported in a critical condition under artificial ventilation on April 6. The MOHP reported this was the 63rd case of highly pathogenic avian influenza in Egypt.
Source of report: Amr Kandeel, Undersecretary for preventative affairs, MOHP
Samir Refaie, Head of Epidemiology and Surveillance Unit, MOHP

The above comments describe the most recent confirmed H5N1 case in Egypt. Unlike earlier cases, there is no mention of contact with poultry.  The lack of contact is not surprising because of the gap between the admission and confirmation dates.  The above detail confirms that treatment was also delayed, which was almost certainly linked to an absence of a poultry contact.  In Egypt, over 6000 patients have been hospitalized as suspect H5N1 patients.  These cases generally have a poultry link and treatment with Tamiflu is begun prior to receipt of test results.  The gap between the admission date of March 28 and treatment date of April 3, strongly suggests that these is no reported link to poultry for this case.

This case follows a spike in confirmed H5N1 in toddlers.  The two prior cases were neighbors who lived in Beheira.  The 4 day time gap between onset dates strongly suggests that there was toddler to toddler transmission, although both cases have a poultry link.  However, the website that describes the patients contains a significant amount of detail, including the district for the two patients, which was Kom Hamada.

The site also details confirmed H5N1 outbreaks in poultry and although there have been 24 outbreaks since March 1, including 7 outbreaks in Beheira, none of the outbreaks were in Kom Hamada, indicating that the Beheira cluster is not linked to H5N1 confirmed poultry.  The presence of confirmed H5N1 in the Beheira governorate, but not the Kom Hamada district, raises concerns that the toddlers were not infected by poultry, especially the second case, who was a neighbor of the first case.

The absence of a confirmed H5N1 in the most recent cases in Egypt adds to concerns that the number of mild H5N1 cases is markedly higher than then number of confirmed cases, and like the Beheira cluster, there is human to human transmission that is silently spreading.

More aggressive testing of symptomatic toddlers that lack a poultry contact is warranted.

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