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Deaths in New Delhi India and Qinghai China Linked Via H5N1?
May 29, 2005
The 121 reported deaths linked to the bird flu deaths at the Qinghai Lake Nature Reserve have not been addressed by announcements out of China. There have been blanket denials of human H5N1 cases, which have specifically mentioned a lack of pneumonia deaths. However, the 121 fatalities in 18 communities in Gangcha county have not been pneumonia deaths. The reported cases had fever and vomiting, but did not have respiratory problems.
Earlier reports of H5N1 deaths in Vietnam included cases that did not initially present as respiratory cases. There was one case well described, in the New England Journal of Medicine, with neurological involvement. Such involvement with H5N1 in poultry and laboratory mice and ferrets is well known, and recent reports on the tiger deaths in Thailand decribed neurologic involvement of H5N1..
The initial reports on the dead geese at Qinghai Lake indicated they did not die of H5N1 infections, suggesting an unusual pathology. The initial reports described the deaths of 178 bar -headed geese. The geese can migrate 1000 miles in a day and many nest in the nature reserve after arriving in May and June from the northern plains of India. The initial dead geese were found on May 4, which would be the time for early arrivals from India.
In early May, New Delhi, in northern India, was experiencing an outbreak of meningitis. A small percentage of cases were laboratory confirmed bacterial meningitis. The case fatality rate was about 10%. The number of cases in India has continued to rise and after a lull in reported cases, the numbers have begun to rise again. Although initial cases were in New Delhi, additional cases near the northern plains have been reported.
Recently, the detection of H5N1 antibodies in three poultry workers in India has been disclosed. The serum from these patients was collected in 2002, detected at the end of 2004, and reported recently. The poultry workers had not traveled in 2002, suggesting locally acquired infections. India has denied H5N1 infections in their report to OIE and specifically mentioned the deaths of 250 pigeons that died at a temple in 2004 in northeast India.
The origin of the H5N1 in the bar-headed geese has not been determined, but the wintering in northern India raises the possibility that asymptomatic geese may have been present in northern India. The coincidence between the outbreak of meningitis in New Delhi and the migration of bar-headed geese to Qinghai Lake in China may be significant.
Unfortunately, neither India nor Chia have reported on the H5N1 status of the dead patients. Only the birds have been laboratory confirmed to be H5N1 positive.
The monitoring of H5N1 in Asia has been scandalously poor and the widespread outbreaks of H5N1 has clearly put the world's health at increased risk. The members of the World Health Association meeting in Geneva recently passed regulations giving the WHO authority to investigate incidents such as those reported in India and China linked to the H5N1 positive geese.
Clearly now is an appropriate time to implement the new regulations and clarify the status of H5N1 in humans in India and China.