21 September 2006

Avian influenza - human cases in Indonesia and Iraq

In August 2006, the World Health Organization (WHO) revised the case definition for human infection with avian influenza A(H5N1) [1]. The revision will help to standardise the reporting and classification of human cases of avian influenza by national and international authorities, and allow comparability of data across time and geographical areas.

Confirmed cases now require a compatible clinical syndrome, a confirmed or suspected exposure to H5N1 in humans, animals or the laboratory, and one of the following laboratory tests:

• Isolation of the virus
• Detection of H5 influenza virus by polymerase chain reaction
• A four-fold increase in antibody against H5N1 from tests taken during the acute phase of illness and also from the convalescent phase
• A single high antibody test taken at least 14 days after the onset of symptoms

Applying these new definitions has led to reclassification of several cases.

Indonesia

WHO have retrospectively confirmed two cases of human avian influenza in Indonesia [2].

• An eight year old girl from Banten province who developed symptoms on 24 June 2005 and died on 14 July 2005.
• A 45 year old man from Central Java province who developed symptoms on 25 November 2005 and has subsequently recovered.

In addition, the Ministry of Health of Indonesia have retrospectively confirmed an additional two cases [3].

• A five year old boy from East Bekasi in West Java province who developed symptoms on 4 March 2006 and died in hospital on 19 March 2006. A field investigation found that the boy was exposed to diseased poultry in the vicinity of his home prior to the onset of symptoms.
• A 27 year old man from Solok in West Sumatra province. The case was identified during the tracing of contacts of the man’s sister who was confirmed to be infected with H5N1 in May 2006. The man cared for his sister whilst she was in hospital and is not known to have had contact with poultry in the days prior to onset of symptoms. Human-to-human transmission cannot be ruled out.

The Ministry of Health in Indonesia has confirmed a new case of human avian influenza in a 14 year old girl from South Sulawesi province [2]. She developed symptoms on 18 June 2006 and died in hospital on 24 June. She is known to have had contact with poultry near her home.

Iraq

The Ministry of Health in Iraq has retrospectively confirmed a case of human avian influenza in a three year old boy [4]. He was hospitalised with a mild illness on 15 March 2006 and has subsequently made a full recovery. Initial tests proved to be inconclusive and Iraq experienced problems with the shipment of specimens for external verification resulting in a delay in diagnosis.

Global Case Totals

The global total of laboratory cases reported by the World Health Organization (WHO) as of 19 September 2006 is in the table below and can be found on the WHO website at: http://www.who.int/csr/disease/avian_influenza/country/

cases_table_2006_09_19/en/index.html

COUNTRY	HUMAN CASES as of 19 September 2006					DEATHS
	2003	2004	2005	2006	TOTAL
Azerbaijan	0	0	0	8	8	5
Cambodia	0	0	4	2	6	6
China	1	1	8	12	21	14
Djibouti	0	0	0	1	1	0
Egypt	0	0	0	14	14	6
Indonesia	0	0	19	46	65	49
Iraq	0	0	0	3	3	2
Thailand	0	17	5	2	24	16
Turkey	0	0	0	12	12	4
Viet Nam	3	29	61	0	93	42
TOTALS	4	46	97	100	247	144

Advice for travellers

Examination of human cases of avian influenza has indicated that the greatest risk for transmission from birds to humans comes when there is close human contact with domestic poultry. This is particularly so in settings of diseased household flocks and when there has been slaughtering, de-feathering, and preparation of poultry for consumption. No cases have been linked to consumption of properly cooked meat or eggs.

There remain no restrictions for travel to countries with avian influenza. Nevertheless, travellers should exercise precautions [5].

The Health Protection Agency (HPA), Centre for Infections has published an algorithm for the management of travellers or visitors arriving from countries (or areas within countries) affected by avian influenza [6]. These regions are revised as new information is provided from the WHO and the World Organisation for Animal Health (OIE) on detection of avian influenza. Countries may be removed from the list if they have been declared free of avian influenza.

The HPA algorithm provides guidance on the recognition, investigation and management of persons with fever or history of fever and respiratory symptoms, and who have had an exposure to persons or birds with suspected avian influenza (H5N1) within seven days of the development of their symptoms. Physicians who see persons whom they suspect may have avian influenza should evaluate them according to this algorithm. The HPA has published a second algorithm to reflect the situation of a traveller from an area (including within the UK) where there is no known avian influenza [7].

References

1. World Health Organization. WHO case definitions for human infection with influenza A(H5N1) virus. 29 August 2006. [cited 21 September 2006] Available at: http://www.who.int/csr/disease/avian_influenza/guidelines/

case_definition2006_08_29/en/index.html

2. World Health Organization. Avian influenza - situation in Indonesia - update 30. 8 September 2006 [cited 21 September 2006] Available online at http://www.who.int/csr/don/2006_09_08a/en/index.html

3. World Health Organization. Avian influenza - situation in Indonesia - update 31. 14 September 2006 [cited 21 September 2006] Available online at http://www.who.int/csr/don/2006_09_14/en/index.html

4. World Health Organization. Avian influenza - situation in Iraq - update 5. 19 September 2006 [cited 21 September 2006] Available online at http://www.who.int/csr/don/2006_09_19/en/index.html

5. NaTHNaC. Avian influenza - advice for travellers to affected areas. 4 July 2006. [cited 21 September 2006] Available online at http://www.NaTHNaC.org/pro/clinical_updates/

avianinfluenza_advice.htm

6. Health Protection Agency. Algorithm for the management of returning travellers and visitors from countries affected by avian influenza (H5N1) presenting with a febrile respiratory illness: recognition, investigation and initial management. 6 September 2006 [cited 21 September 2006] Available online at http://www.hpa.org.uk/infections/topics_az/influenza/avian/

algorithm.htm

7. Health Protection Agency. Algorithm for the management of persons resident in the UK arriving from areas not known to have avian influenza H5N1 presenting with febrile respiratory illness after close contact with sick, dying or dead birds: recognition, investigation and initial management. 6 September 2006 [cited 21 September 2006]. Available online at: http://www.hpa.org.uk/infections/topics_az/influenza/avian/

documents/F3notraveltoH5N1060906.pdf