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Pandemic Bird Flu - Patient to Nurse Transmission in Thai Binh

Recombinomics Commentary

April 23, 2005

>>The question now is whether bird flu in Vietnam has begun passing among humans.

If it has, Nguyen Duc Tinh, a nurse who treated Tuan at the Thai Thuy district health center and fell sick with bird flu soon after, would be a likely instance. Tinh, 26, said he had no contact with poultry for a month beforehand despite government accounts attributing his illness to infected chickens.

Tinh said he was the hospital staff member who had the closest contact with Tuan during his brief stay at the health center, taking his blood pressure and temperature, giving him injections and helping him walk. Within a week, Tinh had developed muscle aches and a high fever, symptoms of what he believed was a common flu. But when the fever subsided and then returned two days later, he grew alarmed.

"Then I suspected I had bird flu," he recalled, his brown eyes widening. "I was really, really afraid of dying."

But just two weeks after joining Tuan in the Hanoi hospital, Tinh was discharged and went back to his village.<<

Media reports are now providing more detail on specific human-to-human cases that signaled the more efficient H5N1 transmission, particularly in northern Vietnam.  The case described above provides detail about the first reported transmission from patient to health care worker, a very big red flag for human-to-human transmission.  The transmission at the time was the longest transmission chain, and symptoms in a second nurse would have extended the chain further.  Although that nurse tested negative, the virus is changing genetically.  This can affect the screening tests.  Moreover, prior false negatives increase the likelihood that the second nurse was also H5N1 infected, consistent with the clinical presentation and contact with confirmed H5N1 cases.

The travel of the index case to Haiphong prior to developing symptoms may have also been relevant.  That is where a family of five were hospitalized on the same day, and a few days later neighbors showed symptoms.  Thus, the version of H5N1 in the north has been circulating for some time. 

Co-circulation of this northern strain with the more lethal southern strain creates conditions for rapid evolution via recombination.  Similarly, migrating birds carrying new sets of sequences as they fly back to the north are cause for considerable concern.

The increased efficiency of human-to-human transmission was clear earlier this year, and familial clusters account for over one third of reported cases.  These frequent human-to-human transmissions have been less obvious to the public because of intense efforts to attribute the human-to-human transmissions to poultry.

The failure of WHO to issue alerts on these clear signals of the emerging pandemic remain scandalous.

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