Commentary
Human
Transmission in H5N1
Toddler Cluster in Beheira Egypt
Recombinomics Commentary
17:56
April 6, 2009
Governorate: Beheira
District: Kom Hamada
Event summary: Boy, age 2, began experiencing fever, cough and runny nose on March 31. He was admitted to Damanhour Fever Hospital on April 1 and received Tamiflu the same day. Infection with avian influenza was confirmed April 2. He reported contact with a dead or sick poultry. He was reported in good general condition on April 6. The MOHP reported this was the 62rd 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
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Date of report: 1 April 2009
Governorate: Beheira
District: Kom Hamada
Event summary: Boy, age 2, began experiencing fever and cough symptoms on March 27. He was admitted to Naaora Fever Hospital on March 30 and received Tamiflu the same day. Infection with avian influenza was confirmed April 1. He was reported contact with dead and sick poultry. He was reported in good general condition on April 6. The MOHP reported this was the 61st 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 are from the SAIDR site in Egypt, which provides detail on human and avian H5N1 outbreaks. The detail helps with some confusion in media reports, which noted that the index case developed symptoms during a visit to his grandparents in Menoufiya, where he was subsequently hospitalized. That report was followed by a confirmed case in Beheira, who was said to be the next door neighbor of the index case (which is supported by the above report indicating both cases were in the Kom Hamada district), raising concerns of human to human transmission.
The above detail changes the disease onset date of the index case to March 27, indicating symptoms began in Beheira prior to his trip to his grandparents and subsequent hospitalization in Menoufiya (see updated map). The earlier onset date also indicates Tamiflu treatment began more than 48 hours after disease onset, yet the patients is currently in “general good condition” and there were no indications that he developed pneumonia or was placed on a ventilator, supporting a “mild” H5N1 infection. The earlier date also creates a four day gap between the disease onset date of the index case and his neighbor, strongly suggesting that the index case infected his neighbor.
The likelihood of next door neighbors developing H5N1 four days apart is remote. Although there has been a spike in confirmed cases in toddlers, the overall number of cases is low and two independent introductions into neighbors is unlikely. This cluster also increases concerns that the number of cases is markedly higher than the confirmed cases because the cases are mild, and only cases with a poultry contact are tested for H5N1. Therefore, cases that resolve without treatment, or after treatment for seasonal flu, would not be counted as a confirmed case.
This cluster also discounts the media myth that transmission is limited to blood relatives. Although there are multiple clusters that do not involve blood relatives, this cluster increases that number, and supports the likelihood of additional unreported cluster due to an absence of testing in patients without a poultry connection.
The human to human transmission would be further supported by a close similarity between sequences from the neighbors, as was seen in the outbreak of mild H5N1 in the spring of 2007. That outbreak involved older children, but the H5N1 infections were also mild and the number of infections was also likely to have been much higher than the confirmed cases, of which 16/17 survived.
Therefore, release of sequence data from the Beheira cluster would be useful as would aggressive testing of toddlers who have symptoms, but lack a poultry connection.
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