So now we can all rest easy because we know where the 6 year old girl (not a boy as the Indon Ministry of Health previously reported) who died recently of H5N1 infection acquired the virus. The source of all H5N1 infections: birds. How do we know? Because an official of the Indonesian bird flu centre says so:
"She had indirect contact with dead chickens near her school," Joko Suyono, an official at the ministry's bird flu centre, said by telephone. The victim, from the city of Cilegon in Banten province, had initially been identified as a six-year-old boy, but Suyono said this was due to a mix up between the hospital where she was treated and a laboratory. The official said that tests on dead chickens found near the girl's school showed they were infected with bird flu."We cannot know whether she touched sick chickens or not because she died. But we know surrounding her school the virus is endemic (in fowl)," he added. Suyono said tests for the virus on people who may have had contact with the girl had proved negative and also said the findings in this case ruled out the possibility of the virus being transmitted between humans. "So far, there have been no human-to-human cases in Indonesia," he said. (Reuters)
Let's parse this. There were dead chickens "near her school." How near? We were told earlier there were no sick poultry within 300 meters. Does this mean they were closer than 300 meters? Or is more than 300 meters still "near". She had "indirect" contact. Which means what? They say they don't know if she ever touch a sick chicken because they can't ask her now but apparently before they were pretty sure she hadn't actually come in contact with a sick bird. Has this changed? And if not, what does "indirect contact" really mean? That sick birds left virus in the area, say in dust or feces, and this little girl became sick from breathing the dust or hand to mouth or eye behavior? And if so, what does this mean about how the virus is transmitted?
The Indonesian authorities have "ruled out" another person as the source, adding that there have been non human-tohuman cases in Indonesia. Except, of course, the notorious Karo cluster. Nevermind.
It may well be that this unfortunate little girl did pick up the virus from birds or an environment contaminated with the virus by birds. But we have the uncomfortable feeling that this is the only acceptable source for Indonesian authorities and that to accept any other source (e.g., an as yet unknown animate reservoir or person to person transmission) they'd have to experience the epidemiologic equivalent of being whacked over the head with a two-by-four.
By that time the rest of us wouldn't be listening to what they were saying anyway. We'd be too busy getting ready.
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Earlier, walkin' home from the supermarket after grabbin' a few groceries. A beautiful Australian ocean front view was making love to my eyes. This happy joy mo was interrupted by seagull poo hitting my shoulder. I reacted calmy, and responded to this poo as if it were a lethal pathogen -- which it could be -- with a couple of tissues, ensuring the feces did not touch any part of my skin (blocking hand to mouth or eye behavior).
I'm 39, not a carefree 6 year old!
Excuse the pun, but with two cases of BF you get....eggroll, a seat on the WHO board, 500 million, endemic cases in the whole country, and the right to extort the rest of the world for a whole new boxload of money!
This to me is the saddest and most telling statement "But we know surrounding her school the virus is endemic"
I wonder when they will act on this knowledge and do something to protect these poor children.
In a related story, please can you comment on the problems that I have found, regarding the Thai man who was supposed to have died of the Bird-Flu as reported yesterday and was declared to have been "Bird-Flu Free" to day.
That is fine, but he was also said to "not have had any contacts with any poultry".
This contradicts a news item from the Vietnam News Agency yesterday, which reported that:
"The man lived next door to his elder brother's cockfighting yard. Recently some of the birds had died of unknown causes"
I personally find reading this kind of reporting frustrating too because I have more questions after finished reading the article than prior.
To me, the holes and inconsistencies could be from either the government or the reporters.
Assuming it's the government officials, who are withholding information, making conclusions prematurely, or simply leaving out some important technical details unsaid, reporters should've asked lots of questions to find out how the conclusions in questions were made.
The problem is that I don't know what was said and what wasn't said at the press conference. We think reporters have been reporting the important information to us, but last year, I did a small study regarding emerging infectious disease reporting, and I found that many supposedly relevant epidemiological information that was explained by officals and experts at press conferences was not included in the final version of news articles!
It makes the already confusing situation more confusing really.
H5N1 bird flu: Spread by drinking water
Risk evaluations of the German authorities BfR/FLI and UBA are fundamentally wrong.
The lethal H5N1 bird flu virus will be strong seasonal in the cold transferred to humans via cold drinking water also in Germany, as with the birds.
Recent research results must worry: So far the virus had to reach the bronchi and the lungs of humans in order to infect man. Now in Indonesia it infects the upper respiratory system (mucous membranes of the throat and mucous membranes of the nose e.g. when drinking and probably also the conjunctiva of the eyes as well as the ear drum skin diaphragm e.g. at showering).
In three cases (Viet Nam, Thailand) stomach and intestine by the H5N1 Virus were stricken, not however the bronchi and the lungs. The virus must have been thus orally taken up, e.g. when drinking contaminated water.
Ground water in Germany used for drinking water is not free from viruses as the German authorities BfR/FLI and UBA wrong insist. The performance of the drinking water processing plants to eliminate viruses in Germany regularly does not meet the requirements of the WHO and the USA. The performance of flocculation and filtration to eliminate viruses from surface water reaches maximally 99.5%. The WHO Drinking Water Guidelines (2004) demands 99.9999% to 99.999999%. The ventilation and high-speed filtration from groundwater to eliminate iron and manganese do not eliminate any viruses. The US Ground Water Rule requires 99.99%. Conventional disinfection procedures by chlorine are poor, because viruses are chlorine tolerant and occur in the raw water not individually, but clumped and therefore by chlorine cannot be achieved.
References
http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/jun060…
CIDRAP
Indonesia suspects ominous H5N1 mutations
Wayan Teguh Wibawan, a microbiologist from Indonesia's avian flu commission, told Reuters that the suspicions are based on preliminary results of genetic tests at laboratories in Indonesia. The amino acid structure of poultry H5N1 samples is becoming increasingly similar to that seen in human H5N1 samples, he said.
The similarity in amino acid structure makes it easier for the virus to attach to receptors on cells that line the throat and lungs, Wibawan told Reuters. The virus would have to attach readily to human cell receptors in order to easily pass from birds to humans, he said.
http://www.who.int/mediacentre/factsheets/avian_influenza/en/index.html…
WHO, Avian influenza (" bird flu") - Fact sheet
THE DISEASE IN HUMANS
The second mechanism is a more gradual process of adaptive mutation, whereby the capability of the virus to bind to human cells increases during subsequent infections of humans.
Swimming in water bodies where the carcasses of dead infected birds have been discarded or which may have been contaminated by faeces from infected ducks or other birds might be another source of exposure. In some cases, investigations have been unable to identify a plausible exposure source, suggesting that some as yet unknown environmental factor, involving contamination with the virus, may be implicated in a small number of cases.
For unknown reasons, most cases have occurred in rural and periurban households . Again for unknown reasons, very few cases have been detected in presumed high-risk groups, such as commercial poultry workers, workers at live poultry markets, cullers, veterinarians, and health staff caring for patients without adequate protective equipment. Also lacking is an explanation for the puzzling concentration of cases in previously healthy children and young adults. Research is urgently needed to better define the exposure circumstances, behaviours, and possible genetic or immunological factors that might enhance the likelihood of human infection.
Assessment of possible cases. Exposure to an environment that may have been contaminated by faeces from infected birds is a second, though less common, source of human infection. To date, not all human cases have arisen from exposure to dead or visibly ill domestic birds. Research published in 2005 has shown that domestic ducks can excrete large quantities of highly pathogenic virus without showing signs of illness.
Clinical features.
Initial symptoms include a high fever, usually with a temperature higher than 38°C, and influenza-like symptoms. Diarrhoea, vomiting, abdominal pain, chest pain, and bleeding from the nose and gums have also been reported as early symptoms in some patients. Watery diarrhoea without blood appears to be more common in H5N1 avian influenza than in normal seasonal influenza. The spectrum of clinical symptoms may, however, be broader, and not all confirmed patients have presented with respiratory symptoms. In two patients from southern Viet Nam, the clinical diagnosis was acute encephalitis; neither patient had respiratory symptoms at presentation. In another case, from Thailand, the patient presented with fever and diarrhoea, but no respiratory symptoms.
References
Dinh PN, Long HT, Tien NTK, Hien NT, Mai LTQ, Phong LH, et al. Risk factors for human infection with avian influenza A H5N1, Vietnam, 2004. Emerg Infect Dis [serial on the Internet]. 2006 Dec [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol12no12/06-0829.htm
EFFECT MEASURE, Bird flu in water. How big a problem? Available from http://www.agoravox.com/article.php3?id_article=5455
Walker K on Webster RG, H5N1 Adapts To Summer Water Heat, TERRA DAILY, Oxford, England (UPI) May 03, 2006. Available from http://www.terradaily.com/reports/H5N1_Adapts_To_Summer_Water_Heat.html
RIVM NL, Schijven FJ, Teunis PFM, Roda Husman AM de, Quantitative Risk Assessment of Avian Influenza Virus Infection via Water. Available from http://www.rivm.nl/bibliotheek/rapporten/703719012.html
BfR/FLI, Zum Risiko der Übertragung des Vogelgrippevirus über Trinkwasser, Gemeinsame Stellungnahme Nr. 017/2006 des Friedrich-Loeffler-Instituts und des BfR vom 22. März 2006. Available from http://www.bfr.bund.de/cm/208/zum_risiko_der_uebertragung_des_vogelgrip…
UBA, Keine Gefahr für Trinkwasser aus den öffentlichen Leitungsnetzen durch Vogelgrippe, Hinweise für Trinkwassernutzer, Stand 19. April 2006. Available from http://www.umweltbundesamt.de/uba-info-presse/hintergrund/vogelgrippe-t…
UBA, Trinkwasser und Aviäre Influenza A/H5N1, Hinweise für Wasserversorger, Stand 19. April 2006. Available from http://www.umweltbundesamt.de/uba-info-presse/hintergrund/trinkwasser-a…
WHO, Questions & Answers on potential transmission of avian influenza (H5N1) through water, Sanitation and Hygiene and ways to reduce the risks to human health. Available from http://www.who.int/water_sanitation_health/emerging/AI_WASH_working_gro…
WHO, Review of latest available evidence on potential transmission of avian influenza (H5N1) through water and sewage and ways to reduce the risks to human health, Last updated 30/05/2006. Available from http://www.who.int/water_sanitation_health/emerging/h5n1background.pdf
WHO, Guidelines for drinking-water quality, third edition, incorporating first addendum, 7, Microbial aspects, 131-141. Available from
http://www.who.int/water_sanitation_health/dwq/gdwq0506_7.pdf
U.S. EPA, Ground Water Rule (GWR). EPA published the Ground Water Rule in the Federal Register on November 08, 2006. Available from http://www.epa.gov/safewater/disinfection/gwr/
SODDEMANN W, Influenza in Deutschland: Als Zoonose durch Trinkwasser übertragbar? Hinweise und Indizien, umwelt-medizin-gesellschaft 18 (1): 49-60. Available from http://www.umg-verlag.de/umwelt-medizin-gesellschaft/105_sodd.html
The primary transmission of the influenza by the bio tables droplet infection is extremely improbably because influenza epidemics
-only in 9% of the cases (season 2004/2005) together with recognized amassments arise.
-regularly first with babies and children begin.
-virologic locally singularly arise (influenza-subtypes and fine classification).
-arise geographically locally singularly.
-in large cities and densely populated areas to be proven not with priority.
-predominantly in the colder regions of Germany arise.
-their maxima regularly in certain circle/circle-free cities reach.
-strictly parallel to the hydrograph curve of the winter cooling sum run.
-by saliva droplets to hardly spread can. Saliva contains far less Influenza viruses than - heavier - the droplets from throats and nose.
The facts
Influenza epidemics step to small extent as well as recognized amassments on (9% of the cases in the season 2004/2005) (RKI 2006). They begin regularly first with babies and children and have in their age groups also their maxima.
Influenza epidemics step virologic locally singularly on (influenza-subtypes and fine classification) (AGI 2007).
Influenza epidemics run also geographically locally singularly. They are not proven with priority in large cities and densely populated areas. They step predominantly in the colder regions of Germany on (the east also in the winter cold continental climate, southeast, altitudes) (RKI 2007). They reach their maxima regularly in certain circle/circle-free cities (absolute front runners: Frankenthal, Worms, district Stoll mountain) (RKI 2007).
Influenza epidemics run strictly parallel to the hydrograph curve of the winter cooling sum.
Influenza epidemics can hardly spread by saliva droplets. Saliva contains far less Influenzaviruses than the substantially heavier droplets from throats and nose (ANONYMOUS 2003) (GOLDMANN 2001).
Human Influenzaviruses could being proven to pigs (faecal and oronasal), game lights (faecal and oronasal), cattle and goats in the eliminations of mammals such as, so that in principle the transmission path from the environment is over waters and the drinking water possible for BROWN (2004) (GRAVES et al. 1975) (KADEN et al. 2001) (KAWAOKA et al. 1986) (LANDOLT et al. 2003) (MARKOWSKA DANIEL et al. 1999) (RKI 1999) (VICENTE et al. 2002) (WEBSTER 1998) (ZHOU et al. 1996) (CARPENTER 2001). With considerable security in the future still further animal species infected with influenza A are discovered (WEBSTER 1998).
Elimination and inactivating of viruses during the drinking water processing
Drinking water is often not filtered in Germany or only roughly. The very small viruses are not removed surely thereby. For groundwater preparation wide-spread filtration plants for the distance of iron and manganese do not possess effect (WHO 2004) regarding the elimination of viruses. Even in Germany as particularly efficiently valid plants for the flocculation and filtration can, also with consideration of the common disinfection procedures, whose efficiency with sinking water temperature decreases [Chlorine and ozone treatment] and with micro organisms clumped in the water are only reduced effective [Chlorine, ozone treatment and UV irradiation], which do not reach from the WHO demanded eliminations and inactivating achievements (WHO 2004).
"Cooling chain of the public potable water supply"
Cold weather is with distance the most important parameter for the preservation of virulent Influenzaviruses in the water. The temperature minimum of the dam water in Germany amounts to during the months January and February 3-4°C. River water has its temperature minimum likewise in January and February of each yearly. Groundwater near the surface has in Germany at the groundwater surface - similar to the soil in 100 cm depth - its temperature minimum of for instance 3°C in February and March. Also from wells of larger depth taken groundwater can be colder with unsatisfactory sealing between the fountain and the surrounding rock by infiltration by surface water affected and therefore than the deeper groundwater. Bach hoists, from which surface water arrives on short ways at the wells, can have the same effect. Bank filtrate from wells, which were bored near the bank by surface waters, accepts the temperature in the winter of the cold surface water. Same applies to wells, from which with surface water enriched groundwater is promoted. The ground temperatures in a meter of depth correspond to the temperatures of the drinking water pipelines shifted frost-protected in the soils. The temperature minima of the ground temperatures in 100 cm depth amount to in Germany during the months February and March 3-5°C (DWD 2007). The temperatures of the drinking water pipelines and the drinking water transported in them adapt themselves to the ground temperatures. In the winter cold raw water remains cold in the drinking water processing plants and after the dressing to drinking water in the water tanks and water pipelines up to the annexe of the consumers. The temperature minimum of the drinking water at the annexe follows in particular the process of cold weather in the soil and in the water pipelines. It stops itself in the months February and March. The cold drinking water is only mixed in the dwellings at the taps with warm water from the house installation. Thus the constant "cooling chain of the public potable water supply" is described from the water winning to the consumers with a drinking water temperature of for instance 4-5°C in the months February and March of each yearly. Cold, young, freshly drinking water, taken out of surface water and badly protected groundwater near the surface as well as out of groundwater from roc, contaminated by Influenzaviruses, can be the abiotische vehicle, which transports virulent Influenzaviruses in the winter with 4-5°C conserved and over the constant "cooling chain of the public potable water supply" to humans.
Transmission paths of the drinking water
Infections by drinking water will not transfer alone by drinking the water. Further transmission paths are the inhalation of aerosols and the contact with the drinking water. Entrance gates with humans are conjunctiva, the nose mucous membrane, the mouth mucous membrane, the ear drum skin diaphragm, wounds and by catheters of affected other mucous membranes.
Conclusions
The primary transmission of the influenza by the bio tables droplet infection is already because of the strict dependence on environmental temperatures extremely improbable. The influenza must be transferred by increasingly a abiotisches vehicle efficient for the propagation of infections with increasing cold weather. Therefore must be searched for the transmission of the influenza for abiotischen vehicles dependent on cold weather. Drinking water is such a abiotisches vehicle. The stated references and indications show that cold drinking water can be that abiotische vehicle, with which virulent human Influenza viruses from the reservoirs arrives to humans and releases predominantly this way the seasonal influenza epidemics. That applies in particular also to the extremely lethal H5N1 bird flu, whose faecal transmission is indisputable.
Sources/References
AGI (2007): Arbeitsgemeinschaft Influenza http://influenza.rki.de/agi
ANONYM (2003): Understanding Sars and other Respiratory Infections May 2003.
http://www.ifh-homehygiene.org/2003/2downloadabledoc/SARS.pdf
BROWN (2004): Influenza Virus Infections of Pigs, Part 1: swine, avian & human influenza viruses. http://www.pighealth.com/influenza.htm ; Part 2: Transmission between pigs and other species. Veterinary Laboratories Agency, UK.
http://www.pighealth.com/influenzaB.htm
DWD (2007): Deutscher Wetterdienst (DWD), Wetterstation Erfurt-Bindersleben, Erdbodentemperaturen aus 100 cm Tiefe
GOLDMANN (2001): Epidemiology and Prevention of Pediatric Viral Respiratory Infections in Health-Care Institutions, Childrens Hospital and Harvard Medical School, Boston, Massachusetts, USA, Emerging Infectious Diseases, Special Issue.
http://www.cdc.gov/ncidod/eid/vol7no2/goldmann.htm
GRAVES et al. (1975): Human viruses in animals in West Bengal: An ecological analysis, Human Ecology, Volume 3, Number 2 / April, 1975, 105-130.
http://www.springerlink.com/content/u5408wx5t622ll82/
KADEN et al. (2001): Gefährliche Verwandtschaft. Schwarzwild - ein natürliches Reservoir für Infektionserreger und Ansteckungsquelle für Hausschweine? Bundes-forschungsanstalt für Viruskrankheiten der Tiere: Forschungsreport 1/2001: 24-28.
http://ticker-grosstiere.animal-health-online.de/20010902-00002/
KAWAOKA et al. (1986): Intestinal replication of influenza A viruses in two mammalian species, Archives of Virology, Volume 93, Numbers 3-4 / December, 1987, 303-308.
http://www.springerlink.com/content/g352726672xj5703/
LANDOLT et al. (2003): Comparison of the Pathogenesis of Two Genetically Different H3N2 Influenza A Viruses in Pigs, J Clin Microbiol. 2003 May; 41(5): 19361941.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&rend…
MARKOWSKA-DANIEL et al. (1999): Seroprevalence of influenza virus among wild boars in Poland. National Veterinary Research Institute, Swine Diseases Departement, Pulawy, Poland. http://www.medwet.lublin.pl/Year%201999/vol99-05/art222-98.htm
RKI (1999): Robert Koch-Institut (RKI) Merkblatt für Ärzte Influenza Verhütung und Bekämpfung (Stand 1999).
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RKI (2006): Infektionsepidemiologisches Jahrbuch meldepflichtiger Krankheiten für 2005, Datenstand: 1. März 2006)
RKI (2007): Robert Koch-Institut Berlin, RKI, Datenbank der nach Infektionsschutzgesetz meldepflichtigen Infektionskrankheiten in Deutschland; http://www3.rki.de/SurvStat/
VICENTE et al. (2002): Antibodies to selected viral and bacterial pathogens in European wild boars from southcentral Spain. J Wildl Dis. 38(3): 649-52.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&li…
WEBSTER (1998): Influenza: An Emerging Disease. Emerging Infectious Diseases 4(3). http://www.cdc.gov/ncidod/eid/vol4no3/webster.htm
WHO (2004): World Health Organization (WHO), 2004, Guidelines for drinking-water quality, 3rd Ed., http://www.who.int/water_sanitation_health/dwq/gdwq3/en/print.html
ZHOU et al. (1996): Influenza infection in humans and pigs in southeastern China, Archives of Virology, Volume 141, Numbers 3-4 / March, 1996, 649-661. http://www.springerlink.com/content/p220471r1r337521/
ZIMMERMANN (2001): Krankheiten des Schweines. Veterinärmedizinische Fakultät der Universität Bern, Vorlesungsskript: 49-51.
http://www.vetmed.unibe.ch/studvet/download/year4/Erkr%20der%20Schweine…
Kontakt: soddemann-aachen@t-online.de