Timeline for Dogubeyazit cluster at
http://www.recombinomics.com/News/01220601/H5N1_Kocyigit_Ozcan_Timeline.html
In looking at the analysis of this cluster, I am filled with the feeling that it points more to human-to-human rather than bird-to-human. How could it be that all members of this family - both immediate and extended - had contact with diseased chicken? Doesn’t it seem more likely that they passed it among themselves?
Yes, I would say H2H and C2C (cluster to cluster) were the primamry movers of H5N1 on these families.
Of course they all had contact with diseased chicken. The question for me is if the virus is prevalent enough among chicken flock to infect more than one family in one area, why did it limit itself to members of one extended family? Especially if some of them don’t even live in the same village.
there could be some infected chicken-poo or chicken-blood on the floor, where they stepped into every now and then. Then they change shoes occasinally, eat some cookie or such with the fingers, voila. It needn’t be done by breathing the virus.
The villages are small and in Dogubeyazit, but the family linkages can’t be ignored. There are other families in Dogubeyazit, but most cases are linked to this extended family. The large numbers if deaths, releases from the hospital, and meals provide many oportunities for H2H and C2C transmission. The latest 6 Ozcans devloped symptoms at a time that might be related to infection by people linked to Fatma Ozcan’s burial.
“Especially if some of them don’t even live in the same village.” anon_22 Exactly!!
gs:
SInce we can’t interrogate individual virons to determine the exact route they took, I don’t see how we can expect to ever have knowledge of the exact means of transmission at such a level of detail. The fact that a patient had contact with another infected person doesn’t prove that he caught the virus from that person, just as the fact that he had contact with infected chickens doesn’t prove that he caught it from the chickens.
It seems to me that we are almost forced to conclude that as evidence of H2H transmission, familial clusters pretty much speak for themselves. I don’t see how there can be any non-arbitrary place to draw a line and say: “clusters bigger than this or more frequent than this are evidence of H2H”.
you can question the people. You can examine the surroundings. It should be possible to figure out the source of infection. Maybe they just don’t want to know. Or they do , but don’t want it to be published. Hey, what’s the email/telefone/snail-mail of this Ozcan-clan ?
It’s still circumstantial evidence. And if circumstantial evidence is good enough, the very existence of the cluster in the first place qualifies; you’re just talking about narrowing it a little.
I’m sure it has been examined. What was the result ?
niman,
“Yes, I would say H2H and C2C (cluster to cluster) were the primamry movers of H5N1 on these families.”
WHO has made a point to say no sustained h2h transmission has been seen. Are they saying, in effect, that the Dogubeyazit cluster might be an h2h fomite situation, not an h2h droplet situation that would be much more volatile?
Or do they steadfastly refuse in any case to see this as h2h?
A week or so ago, a woman posted here who said you’d just assurred her (on curevents, I think) that testing would show h2h if h2h had taken place. Could you refute or clarify?
WHO is palnning on collecting 10,000 serum samples. Antibodies in contacts would be a good indication of H2H.
However, the data are already pretty overwhelming. Here’s another Ozcan added
http://www.recombinomics.com/News/01230601/H5N1_Kocyigit_Ozcan_Grows.html
The level of deatil is clear from the clusters. There are now 6 families that are related, live in Dogubeyazit, and have been hospitalized with bird flu symtoms. This chain has been going on for over a month.
Please forgive me for being dumb but I need someone to explain to me in layperson’s language how it is unlikely that the family members didn’t all get B2H infection from being exposed to a flock of infected chickens, perhaps at a family gathering? The explanations on the recombinomics site just don’t sink into my little brain.
Let me try and give a very simplified explanation:
1 For B2h, if the virus is prevalent enough among chicken flock to infect more than one family in one area, why did it limit itself to members of one extended family and not several unrelated families? Especially if some of the people infected don’t even live in the same village but are related by blood and so presumably could have visited each other.
2 Timing - if person A shows symptoms on Day 0, persons B&C show symptoms on Day 5, persons D&E&F&G show symptoms on Day 11 after attending the funeral of C, what are the chances that this is a complete coincidence and they all just took turns getting infected from the birds once every few days?
anon_22
this is the part I don’t get:
it seems logical to me that the virus would limit itself to one family if they were all at someone’s home and say, stepping in poop, or eating chicken. No other people would be around to come in contact with the infected birds. Like, if you went to a relative’s home for a funeral and a cousin had the regular flu and gave it to everyone else.
Also, if the flu has gestation period of a few days then wouldn’t make sense that not everyone would show symptoms at exactly the same time due to individual variation? I can see that its a coincidence that DEFG all were symptomatic on the same day, but why specifically does this indicate H2H as opposed to B2H?
Please help me understand!
To add to anon-22, here’s an additional and very worrying wrinkle. In most cases, people infected in SE Asia had VERY close contact with infected poultry (i.e. killing and/or plucking them). From what I can gather, the only contact that some members of this extended family had with sick birds was eating cooked chicken. Even if improperly cooked, this implies a far more contagious virus in terms of B2H transmission. And if it was so contagious from birds, why on earth didn’t many other families in the village also get sick??
So it defies logic that H2H wouldn’t be a major suspicion with this cluster and yet WHO keeps downplaying it as highly unlikely and saying everything still points to B2H.
The information that Niman has revealed (and, it could be argued, that WHO has covered up,) seriously challenges their working theory for the primary manner of infection in Turkey.
I find this extraordinarily alarming, as I strongly feel that we need to be able to trust WHO if this is not going to go very, very badly.
Could cultural differences be a key? If they are moslem, they would be using prayer rugs, praying towards Mecca. Do they use chairs and tables at meals, or do they sit on carpets and eat together closer to the ground. I like to sleep on a sheepskin on the floor. Is their bedding, western or more like futons. Every detail of their interactions would have to be taken into consideration. In some cultures you eat with your fingers. In some cultures men embrace on meeting. Could prepared food have been brought to the funeral, much as in our culture people will bring casseroles and food to a house so the family doesn’t need to cook. In some villages they might have bedding up on shelves, with the hearth underneath, to keep warm when the weather is cold. And after all it is winter now. I don’t know the latitude, so don’t know the temp. range. I hesitate to post this as it seems out of the relm of useful speculation, but one never knows when some minor detail holds the key.With prayer rugs, the men would have taken their own to a relatives house, and unfurled it with some virus that they left behind.
Let me repeat my earlier question to niman which has applicability to arguments on other threads.
Can these supposed h2h cases be due to droplet / aerosol transmission, or can they somehow be due mainly to direct contact including fluid excretia / fomites…in effect, “weak” h2h. I believe that was one possibility WHO used to downplay “sustained” h2h transmissibility if not deny it altogether. The implication was that the Dogubeyazit virus somehow isn’t airborne, therefore, not sustainable. That opinion might be nonsense, but I think I might be able to locate it somewhere in these pages.
WHO is careful to avoid concluding h2h of any kind owing to implications of that and subsequent actions warranted. They’re in a squeeze between discounting h2h in Dogubeyazit cluster and warning already worried Britons that pandemic influenza might be imminent.
Interesting questions, Lilly. There has already been at least one cultural factor that was seriously raised—i.e. people bringing chickens into their homes in cold weather.
Dubina, the irony in WHO’s ultra-conservative approach is that the 21 plus however many more cases in Turkey will have to be added to their official count sooner or later. At this rate, it will be so far behind the media reports that they are going to confuse a lot of people into mistakenly thinking it is a second Turkish outbreak and you’ll end up with an unfounded panic!
Yes, and how many more Turkeys or Super Turkeys to Phase 4?
Here is a graph of the cases Dr. Niman pulled together created by the amazing Cgresley at Current Events. Kinda interesting.
That is very interesting. It would be even more helpful if he could include the dates of family get-togethers, who was present, the dates of any known contacts with poultry, etc.
That poor family, though — they must be wondering why they have been so cursed!
Here’s another graph, this time at the h5n1 avian flu blogsite. Also kinda of interesting.
This is the sort of work amateurs can put together in their spare time. Imagine if we had an Organization devoted to World Health with billions of dollars and professional epidemiologists working full time! Boy, we’d have data and elegant graphs coming out the wazoo, wouldn’t we? Well, wouldn’t we?
That was awesome Monotreme … you beat me to it! Great graphs!!
“Boy, we’d have data and elegant graphs coming out the wazoo, wouldn’t we? Well, wouldn’t we?”
We being Flu Wiki, I’m not so sure. I sent a couple of test graphs (Infectious Disease by kind by month in China, one, cases, the other, Fatalities) to Dem or Pogge a month or so ago to ask if graphs were supported…and I got that they’re not for some reason, maybe being too departed from normal activities.
But charts and graphs are way good for stuff like this.
technology doesn’t help us; we have trouble with graphs, but we could do screenshots or jpgs of graphs. That’s an interesting site. i’ve forwarded it to revere (the epidemiologist of the editors).
Elegant. Sending the Armchair Epidemiologists Blog printout to my son in Seattle, who trained at Yale. This might be his cup of tea.
Wow. Well done!
Cheerio!
007
Dem,
“technology doesn’t help us; we have trouble with graphs, but we could do screenshots or jpgs of graphs.”
The ball’s in your court; we (posters) could have done what the other sites did. I’m sure we’ll see many more opportunities to clarify reports and data.
no, the ball’s in your court. What, are you just a kibitzer? ;-)
revere’s early line is that it is interesting material, and should be used as a basis of looking carefully at the family exposures, etc, i.e., field work, but that threre are other mathematrical functions that could fit equally welll (and there’s nothing magic about R0 of 2. I’ve asked him for a fuller explanation, which I hope he’ll put up at Effect Measure.
Very interesting graph — whether or not there was H2H, it certainly suggests that was one option that should be vey carefully explored before being downplayed, as WHO is doing. Otherwise it looks like they’re trying to fit the data to keep the “no H2H” theory alive instead of the other way around.
The only way to dismiss this sort of speculation, if it’s wrong, is to confront it and show exactly why it can’t be so.
Anyways, interesting that so far the mortality in this whole area (also generally in Turkey) seems to be lower than anticipated. Isn’t that good news?
Until we’ve seen health care workers with BF, it seems rather obvious that we’re not seeing H2H (at least anything close to efficient H2H).
alexis-re: “Until we’ve seen health care workers with BF”. I agree-that’s my red flag. And, my fear factor. I’m a health care worker.
If health care workers are being very diligent about taking all the right precautions, you shouldn’t see them with H2H. But I remember Grace cringing at something they were reportedly doing or not doing in terms of precautions at the Van Hospital early on.
Also, the mortality for the first four cases was terrible — three of the four kids died, despite the best efforts of the Van hospital staff to save them. A lot of the subsequent cases received treatment very early, some even before the onset of symptoms, and they mostly did much better. That points to early treatment being a critical factor and it doesn’t reassure me because in a full pandemic, with hospitals overwhelmed, most of us wouldn’t have access to ventilators, Tamiflu and hospitals that can pull out all the stops.
The mortality rate in Indonesia continues to be terribly high — 14 fatalities out of the WHO’s 19 lab confirmed cases (although there are almost certainly other cases that have been missed).
The worst part, and the part that doesn’t seem to be letting up, is this virus seemingly selectively targetting children and teens — it’s an awful thing to consider as a parent, and it must be agonizing for the families of all these children who have died.
Osterhom made a gtreat point today on Oprah re: asking halth care workers to go to work and risk exposingtheir families to this disease-he pointed out that with the fragile supply chain and “Just in time (JIT)” ordering system everyone uses-how do you entice health care workers to go to work, with no masks, gloves Tamiflu for themselves or family? Check this out on Tamiflu:
“Although Asia is considered a hotbed for the lethal flu virus, it was decided at last week’s international avian flu prevention meeting in Japan that 300 million courses of Tamiflu donated by Roche will be divided equally and stored at the WHO’s headquarters in Switzerland and in the United States, a decision that would leave Asia vulnerable to a widespread outbreak.”
I don’t trust either the WHO or the US government to get these meds anywhere in a timely manner! (Look at their “response” time to the first village in turkey. A week.)
from: http://tinyurl.com/becwm
Name: I agree with all of your points. I think the care patients receive in different countries, and perhaps in different regions of the same countries, may affect survival rate. I suspect early, and proper, use of Tamiflu does lower mortality rate. Many of the recovered appear to have been in the hospital for a long a time. What would happen during a pandemic? With no care, we might jump back up to a 70% mortality rate, as difficult to accept as that number may be. anon_22 mentioned the advantages of “flattening” the curve of infections which would allow more people to receive proper care. I agree that that might decrease mortality rates.
The targeting of children and young adults is the most tragic part of this story. No matter what the fatality rate ends up being, the suffering has been and will continue to be quite terrible.
“If health care workers are being very diligent about taking all the right precautions, you shouldn’t see them”
If (a big if) it goes H2H, they will be unable to be “diligent” enough to prevent infections….especially in third world countries. Take a review of some of the pictures from the Van hospital. Based on their apparent level of “diligence” I would srongly believe infections within those healthcare workers if there were any H2H infections occurring.
There are several levels of H2H. Right now the H2H and C2C (cluster to cluster) are between family members (who believe the WHO propaganda that there is little H2H),
Dogubetazit cluster graph
http://www.curevents.com/vb/showthread.php?p=275303#post275303
what levels ? Why should c2c be different from this h2h ? How does the virus enter the human body ? In which organ does it enter ?
I’ve gone back and re-read (courtesy of Crofsblog) the Middle East news headlines of recent weeks in light of the confirmed case in Iraq. I was astonished afresh at how quickly and adamantly the WHO’s Dick Thompson and Ms Cheng dismissed the case of the Iraqi teen, even as local officials and her own doctors were insisting that H5N1 hadn’t yet been ruled out. I also read elsewhere that she was only re-tested at her doctors’ insistence. The WHO certainly has some explaining to do on that one.
The Jan 20 headlines included a suspected human case in Lebanon, and widespread culling and/or requests for assistance from Syria and Armenia — which admitted they didn’t have the resources to ID human cases of H5N1 if they had them. Iraqi Kurdistan started culling poultry weeks ago, like many of Turkey’s neighbours. Bloggers in Kurdistan say there is widespread fear among the population that bird flu has been around for a while — many people have stopped eating chicken or eggs. We wouldn’t expect to hear anything from Iran right now anyway, but putting this all together does raise the possibility that we could be talking about a bigger regional problem in terms of human infections than just Turkey and Iraq.
Given the realities of politics, poverty and war in this region, not to mention the overlay of the Kurdish population across the porous borders of at least four states that don’t much like each other, this is a very bad place for this to be happening.
here’s again, what WHO wrote on 30 January 2006:
see http://www.setbb.com/fluwiki2/viewtopic.php?p=38&mforum=fluwiki2#38
if this is badly formatted.
The outbreak was investigated by international teams coordinated by WHO, including teams of experts drawn from the Global Outbreak Alert and Response Network. Teams in Ankara and Van Province have now completed their work, which has included an overall assessment of the epidemiological situation, the effectiveness of control measures, and the risk of further human cases. Staff departures took place over the weekend. Mechanisms of close collaboration with the Ministry of Health, established during the outbreak, will remain in place.
Epidemiologists in Van investigated several clusters of childhood cases in families from the Dogubayazit district, where the majority of patients, and all fatal cases, resided. Field investigations, including interviews with family members, have found that almost all cases had a documented history of direct exposure to diseased or dead poultry.
The investigation found no clear evidence of human-to-human transmission and no evidence that the virus is now spreading more easily from birds to humans. The vast majority of cases have occurred in children aged 15 years or younger. This age pattern remains puzzling, as adult members in some families were engaged in such high-risk behaviours as the slaughtering of obviously ill birds, yet did not develop infection. This observation further supports the possibility, raised previously during field investigations in Asia, that some as yet unidentified genetic or immunological factor may influence the likelihood of human infection.
Monitoring of patient contacts and of staff at hospitals treating patients found no evidence of infection in these groups, further supporting the conclusion that, in Turkey as elsewhere, the virus is not spreading easily from person to person.
The WHO team found that patients received a high quality of clinical care. The rapid detection of cases, facilitated by high public awareness of the disease, may have contributed to the lower fatality seen in Turkey compared with other countries reporting recent cases.
On 16 January, WHO established a virtual network of clinicians experienced in the management of H5N1 infection and other severe respiratory diseases, allowing Turkish doctors to confer, in real time, with experts elsewhere. Three teleconferences have been held. At present, all evidence, including laboratory and radiological findings, suggests that the disease seen in Turkey is similar to that seen in the Asian outbreaks. In all outbreaks, severe pneumonia and a rapid progression to respiratory failure have been characteristic features in severe cases of infection.
Data on cases in the Turkish outbreak show that patients were hospitalized between 31 December 2005 and 13 January 2006. Dates of symptom onset indicate that all infections were acquired prior to the implementation of control measures. These have included heightened surveillance for poultry outbreaks, culling operations, intensive public information campaigns, contact tracing and prophylactic or post-exposure administration of oseltamivir, and good infection control practices in hospitals managing patients or investigating possible cases.
see http://www.who.int/about/licensing/rss/en/ for further
Old threads being closed.