Chinese son likely gave bird flu to father: report
Posted in xn--kfs74mzzid01b.com edit by anonym on January 7th, 2009
Chinese son likely gave bird flu to father: report
Mon Apr 7, 2008 11:32pm BST
By Maggie Fox, Health and Science Editor
WASHINGTON (Reuters) - A 24-year-old Chinese man who died of bird flu in December passed the virus directly to his father in a rare case of human-to-human transmission of the virus, doctors reported on Monday.
Chinese officials had already said they believed the younger man infected his 52-year-old father, who survived, but genetic sequencing and other checks confirmed this was likely, the researchers said.
"In this family cluster of confirmed cases of infection with highly pathogenic avian influenza A (H5N1) virus in mainland China, we believe that the index case transmitted H5N1 virus to his father while his father cared for him in the hospital," they wrote in the Lancet medical journal.
H5N1 avian influenza is regularly breaking out in birds across Asia, the Middle East, Africa and Europe. It only rarely infects humans but has killed 238 out of 376 people known to have been infected since 2003.
Most have been directly infected by a sick bird, but in a few rare cases, one person appears to have infected another. These have been documented in Indonesia and, just last month, between two brothers in Pakistan.
Most have been among people who are genetically related and this also appears to be the case with the two Chinese men, the researchers said. Some experts believe there may be a genetic susceptibility to H5N1 infection.
The fear is that the virus will acquire changes that allow it to be passed from one person to another more easily. This could cause a pandemic that could kill tens of millions of people globally, so experts are carefully studying every case of transmission.
Yu Wang of the Chinese Centre for Disease Control and Prevention in Beijing and colleagues investigated the cases of the man and his son, who were diagnosed within a week of each other in December 2007 in Jiangsu Province.
They also tested 91 people the two men had come into close contact with. None of these people became infected.
The young man had a high fever, cough and watery diarrhea and his father nursed him intensively in the hospital.
The younger man died but his father got the flu drugs Tamiflu and rimantadine as well as serum from a woman inoculated with an experimental H5N1 vaccine and recovered.
"With the exception of occasional infection in health workers, all published incidents of possible or probable person-to-person transmission report transmission between genetically related individuals," Nguyen Tran Hien of Vietnam's National Institute of Hygiene and Epidemiology in Hanoi, and colleagues wrote in a commentary.
"Although this finding could be related to the intensity and intimacy of contact between family members, host genetic factors might also play a part in susceptibility to H5N1," they added. So anyone in close, prolonged contact with an H5N1 victim should get flu drugs just in case, they said.
Last week the World Health Organization said some human-to-human spread likely occurred when three brothers in Pakistan became infected with H5N1 last year.
The largest known cluster of human bird flu cases occurred in May 2006 in Indonesia when at least 7 family members died.
(Editing by Philip Barbara)
* Medical News: Flu & URI
Avian Flu Jumped from Dying Son to Caregiver Father
By Michael Smith, North American Correspondent, MedPage Today
Published: April 07, 2008
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine. Earn CME/CE credit
for reading medical news
BEIJING, April 7 -- A man who died late last year of highly pathogenic avian flu infected his father in one of the few "probable" cases of human-to-human transmission that have been reported, researchers here said.
The infection likely occurred while the 52-year-old father cared for his 24-year-old son, who was severely ill, according to Yu Wang, Ph.D., of the Chinese Center for Disease Control and Prevention, and colleagues.
Although nearly 100 close contacts were tested for the H5N1 virus, the outbreak was limited to the father and son, suggesting a potential genetic susceptibility to infection, Dr. Wang and colleagues said online in The Lancet.
Only a few cases of suspected human-to-human transmission of the virus have been reported -- the largest series in Indonesia in 2006, when seven members of the same family became infected and six died (See: Indonesian Bird Flu Outbreak Raises Pandemic Fears Anew).
But public health authorities worry that small genetic changes in the virus, now widespread among poultry, might one day allow it to pass easily from one person to another, setting the stage for an influenza pandemic.
In most cases, people are infected after prolonged contact with infected poultry. As of April 3, the World Health Organization had reported 378 confirmed cases, 238 of them fatal.
In the first Chinese case, Dr. Wang and colleagues said, there was no obvious link to infected poultry. The young man visited a market six days before the onset of illness, but had not been within 10 meters of the poultry, they said.
A later investigation showed no sign of infected poultry at that market or at another, visited later by his father.
The man developed transient chills and sweats in the fall of 2007 and on Nov. 24 he developed a fever of 38.8°C, malaise, and chills, and was treated with oral antibiotics as an outpatient the next day.
Three days later, he was hospitalized with persistent fever, chills, headache, myalgia, sore throat, cough, and sputum production. On admission, he had lymphopenia, moderate thrombocytopenia, and left-lower-lobe pneumonia.
A blood culture taken on Nov. 28 yielded Salmonella choleraesuis, so he was treated for bacterial infection.
The man developed progressive dyspnea, copious frothy sputum production, watery diarrhea, and pneumonia and despite broad-spectrum antibiotics, corticosteroids, and mechanical ventilation, died of acute respiratory distress syndrome, disseminated intravascular coagulation, and multiorgan failure on the fifth day in the hospital.
An endotracheal aspirate obtained, just before death, was positive for H5N1 by real-time polymerase chain reaction, the researchers said, and the virus itself was isolated.
The patient's father helped care for him in the hospital, without respiratory protection until the last day, Dr. Wang and colleagues reported. He was exposed to frequent coughing, helped to dispose of soiled clothes and bedsheets, and cleaned a toilet and spittoon used by his son.
The man, a retired engineer, developed a fever of 38.1°C, chills, and cough on Dec. 3. He took one 75-mg dose of oseltamivir (Tamiflu) that had been distributed to contacts of his son for prophylactic purposes.
The next day, he was hospitalized with fever, mild thrombocytopenia, and bilateral pneumonia, and treated with levofloxacin (Levaquin), corticosteroids, and oseltamivir. Rimantadine (Flumadine) was started on the third day.
Despite treatment, he required positive pressure ventilation. On Dec. 7, he received two transfusions of plasma from a 30-year-old woman who had received two doses of inactivated whole-virion H5N1 vaccine in a phase I clinical trial.
The patient's fever resolved that night and a chest radiograph on Dec 12 showed improvement in the right upper and bilateral lower lobes.
H5N1 virus was isolated from a throat swab collected on day four of the patient's illness, and H5N1 viral RNA was detected in throat and stool specimens up to 10 days after the onset of illness.
The patient was discharged 22 days after admission with a full recovery.
As in the case of his son, researchers could find no evidence that the man had been in contact with infected poultry.
While the initial source of the infection remains a mystery, Dr. Wang and colleagues said there's little doubt that the son infected the father, because genomic sequencing showed that viral strains isolated from the two were identical but for one non-synonymous coding change.
The researchers said the case does not imply that the virus has acquired the ability to transmit more easily from person to person.
Indeed, with the exception of occasional infections of healthcare workers, all cases of "possible or probable person-to-person transmission" have been among genetically related individuals, according to Jeremy Farrar, M.D., Ph.D., of the Hospital for Tropical Diseases in Ho Chi Minh City and Oxford University, and colleagues.
The authors noted several limitations including the inability to elicit a complete exposure history from the index case and the fact that it was difficult to trace all contacts who came within one meter of the cases.
In an accompanying commentary, Dr. Farrar and colleagues said that might be explained by continued close contact among infected and non-infected family members.
But "host genetic factors might also play a part in susceptibility to H5N1," they said.
Studying such factors, they said, might "help to clarify the nature of the species barrier and the conditions necessary for widespread transmission between people."
The study was supported by the Chinese Ministry of Science and Technology, the NIAID, and the China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases. The researchers reported no conflicts.
Dr. Farrar and colleagues reported no conflicts.
Primary source: The Lancet
Source reference:
Wang H, et al "Probable limited person-to-person transmission of highly pathogenic avian influenza A (H5N1) virus in China" The Lancet 2008; DOI: 10.1016/S0140-6736(08)60493-6.
Additional source: The Lancet
Source reference:
Hien NT, et al "Person-to-person transmission of influenza A (H5N1)" The Lancet 2008 DOI: 10.1016/S0140-6736(08)60494-8.
If a more transmissible viral strain was emerged in souther China - densely populated - at this point there would be hundreds of thousands of cases, or millions.
Calm down, press!
China is a hot spot these days, Olympic torch permits.
doi:10.1016/S0140-6736(08)60493-6 (http://dx.doi.org.proxy.library.vcu.edu/10.1016/S0140-6736(08)60493-6) http://www.sciencedirect.com.proxy.library.vcu.edu/scidirimg/icon_doi.gif (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=HelpURL&_file=doi.htm&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=dfc755925714843327f52baa9da7671d)
© 2008 Elsevier Ltd .
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(http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#cor1), http://www.sciencedirect.com.proxy.library.vcu.edu/scidirimg/entities/REemail.gif (wangyu@chinacdc.cn)
aJiangsu Provincial Centre for Disease Control and Prevention, Nanjing, China
bOffice for Disease Control and Emergency Response, Chinese Centre for Disease Control and Prevention (China CDC), Beijing, China
cState Key Laboratory for Infectious Disease Prevention and Control, National Institute for Viral Disease Control and Prevention, China CDC, Beijing, China
dJiangsu Provincial People's Hospital, Nanjing, China
eNanjing Secondary People's Hospital, Nanjing, China
fNajing Centre for Disease Control and Prevention, Nanjing, China
gSinovac Biotech Co, Beijing, China
hInfluenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
Available online 7 April 2008.
| Refers to: | http://www.sciencedirect.com.proxy.library.vcu.edu/scidirimg/clear.gif | Person-to-person transmission of influenza A (H5N1) The Lancet, In Press, Corrected Proof, Available online 7 April 2008 Nguyen Tran Hien, Jeremy Farrar and Peter Horby SummaryPlus (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-2&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=1&_fmt=summary&_orig=browse&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=ba8e4bc7028e9eab594ad629e22c7d77) Full Text + Links (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-2&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=1&_fmt=full&_orig=browse&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=0acc44c882bed52ae0cfc226f7159728) PDF (39 K) (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MImg&_imagekey=B6T1B-4S7G10B-2-1&_cdi=4886&_user=709070&_orig=browse&_coverDate=04%2F07%2F2008&_sk=999999999&view=c&wchp=dGLbVlW-zSkWA&md5=c5bbc2b98363d8090872055f7b290fdb&ie=/sdarticle.pdf) |
| Referred to by: | http://www.sciencedirect.com.proxy.library.vcu.edu/scidirimg/clear.gif | Person-to-person transmission of influenza A (H5N1) The Lancet, In Press, Corrected Proof, Available online 7 April 2008 Nguyen Tran Hien, Jeremy Farrar and Peter Horby SummaryPlus (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-2&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=1&_fmt=summary&_orig=browse&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=ba8e4bc7028e9eab594ad629e22c7d77) Full Text + Links (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-2&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=1&_fmt=full&_orig=browse&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=0acc44c882bed52ae0cfc226f7159728) PDF (39 K) (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MImg&_imagekey=B6T1B-4S7G10B-2-1&_cdi=4886&_user=709070&_orig=browse&_coverDate=04%2F07%2F2008&_sk=999999999&view=c&wchp=dGLbVlW-zSkWA&md5=c5bbc2b98363d8090872055f7b290fdb&ie=/sdarticle.pdf) |
Summary
Background
In December, 2007, a family cluster of two individuals infected with highly pathogenic avian influenza A (H5N1) virus was identified in Jiangsu Province, China. Field and laboratory investigations were implemented immediately by public-health authorities. Methods
Epidemiological, clinical, and virological data were collected and analysed. Respiratory specimens from the patients were tested by reverse transcriptase (RT) PCR and by viral culture for the presence of H5N1 virus. Contacts of cases were monitored for symptoms of illness for 10 days. Any contacts who became ill had respiratory specimens collected for H5N1 testing by RT PCR. Sera were obtained from contacts for H5N1 serological testing by microneutralisation and horse red-blood-cell haemagglutinin inhibition assays. Findings
The 24-year-old index case died, and the second case, his 52-year-old father, survived after receiving early antiviral treatment and post-vaccination plasma from a participant in an H5N1 vaccine trial. The index case's only plausible exposure to H5N1 virus was a poultry market visit 6 days before the onset of illness. The second case had substantial unprotected close exposure to his ill son. 91 contacts with close exposure to one or both cases without adequate protective equipment provided consent for serological investigation. Of these individuals, 78 (86%) received oseltamivir chemoprophylaxis and two had mild illness. Both ill contacts tested negative for H5N1 by RT PCR. All 91 close contacts tested negative for H5N1 antibodies. H5N1 viruses isolated from the two cases were genetically identical except for one non-synonymous nucleotide substitution. Interpretation
Limited, non-sustained person-to-person transmission of H5N1 virus probably occurred in this family cluster. Funding
Chinese Ministry of Science and Technology; US National Institute of Allergy and Infectious Diseases, National Institutes of Health; China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases.
Article Outline
- Introduction (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#secx1)
- Methods (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#secx2)
- Patients and procedures (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#secx3)
- Role of the funding source (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#secx4)
- Results (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#secx5)
- Discussion (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#secx6)
- Acknowledgements (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#ack001)
- References (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bibl001)
- Discussion (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#secx6)
Introduction
As of April 2, 2008, 376 cases of infection with highly pathogenic avian influenza A (H5N1) virus, with 238 deaths, had been reported from 14 countries since November, 2003.1 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib1) Although most cases have been sporadic, about 25% have occurred in clusters of two or more epidemiologically linked people.[2] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib2) and [3] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib3) Clusters occurred in 19974 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib4) and 20035 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib5) in Hong Kong (special administrative region [SAR] of China), and during 2004–07 in Indonesia,[6] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib6), [7] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib7) and [8] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib8) Turkey,9 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib9) Azerbaijan,10 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib10) Vietnam,11 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib11) and Thailand.[11] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib11) and [12] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib12) Limited person-to-person transmission of the virus has been strongly suggested in the largest cluster in Indonesia6 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib6) and in Thailand.12 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib12) Previous cluster investigations did not adequately assess whether person-to-person transmission had occurred among exposed contacts. Illness surveillance combined with seroepidemiological investigations in exposed contacts allows a comprehensive assessment of H5N1 virus transmission.
In December, 2007, two cases of infection with H5N1 virus in one family were identified within a week in Nanjing, Jiangsu Province, China. Field and laboratory investigations were implemented immediately by public-health authorities. We report the epidemiological, clinical, and virological findings of this family cluster of confirmed H5N1 cases, including assessment of potential spread to exposed contacts. Methods
Patients and procedures
Epidemiological and clinical data were collected through interviews and review of medical records. Investigation staff interviewed case two and relatives of both cases to verify reported exposure histories during the 2 weeks before the onset of symptoms, to validate timelines of events, and to identify close contacts. We were unable to interview the index case (case one) because he was severely ill at the time of diagnosis and died on the next day. Households and places known to have been visited by the cases in the 2 weeks before the onset of illness were investigated to assess poultry and environmental exposures.
Respiratory and stool specimens were collected from the two patients during hospitalisation and placed in sterile viral transport medium for H5N1 testing.13 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib13)
RNA was extracted from specimens with the RNeasy mini kit (Qiagen, Valencia, CA, USA) as per the manufacturer's protocol and tested by conventional reverse transcriptase (RT) PCR as recommended14 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib14) and by real-time RT PCR with H5N1-specific primers and probes.15 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib15) These assays were done in biosafety level (BSL) 2 facilities at Jiangsu Centre for Disease Control and Prevention (CDC), Nanjing, China, and the National Influenza Centre of the Chinese CDC (China CDC) in Beijing. Respiratory specimens were inoculated in amniotic cavities of pathogen-free embryonated chicken eggs for viral isolation16 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib16) in enhanced BSL 3 facilities at the National Influenza Centre.
Full genomic sequencing was done on extracted viral RNA. cDNA synthesis and PCR amplification of the coding region of the eight gene segments were done with a one-step RT PCR kit (Qiagen) with gene specific primers (available on request from the authors). The PCR products were purified with the Qiagen QIAquick gel extraction kit and used as templates for nucleotide sequencing. Sequencing reactions were done with the ABI BigDye terminator sequencing kit with reaction products resolved on an ABI 3730XL DNA sequencer (Applied Biosystems, Foster City, CA, USA). Nucleotide sequences were analysed with the DNASTAR package (Lasergene, Madison, WI, USA). Phylogenetic analysis was done by neighbour-joining method with MEGA version 4. The nucleotide sequences obtained from this study are available from GenBank (accession number EU434686-EU434701 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=RedirectURL&_method=externObjLink&_locator=genbank&_cdi=4886&_plusSign=%2B&_targetURL=http%253A%252F%252Fwww.ncbi.nlm.nih.gov %252Fentrez%252Fquery.fcgi%253Fcmd%253Dsearch%2526 db%253Dnucleotide%2526doptcmdl%253Dgenbank%2526ter m%253DEU434686-EU434701[accn])).
Close contacts were placed under daily surveillance—by telephone or in person—for fever and respiratory symptoms for 10 days after their last exposure to a patient infected with H5N1 virus. Close contacts were defined as individuals known to have been within 1 m, or had contact with respiratory secretions or faecal material, of a patient with H5N1 any time from the day before the onset of illness to when the index case died or during the period that case two was hospitalised. Chemoprophylaxis with oseltamivir (75 mg orally once a day for 7 days) was recommended and distributed to contacts.
Following written informed consent, a structured questionnaire was used to gather demographic information and data on use of personal protective equipment, oseltamivir chemoprophylaxis, illness symptoms, and potential H5N1 risk factors (eg, poultry contact, visiting poultry markets, contact with individuals with febrile respiratory symptoms) during the 2 weeks before the last exposure to patients with H5N1.
Respiratory specimens were gathered from close contacts with febrile respiratory illness during the 10-day observation period for H5N1 testing. Contacts were asked to have acute and convalescent sera (≤1 week, and ≥3–4 weeks after the last exposure to a patient with H5N1, respectively) collected for H5N1 serological testing.
H5N1 serological testing was done by microneutralisation assay in a BSL 3 enhanced laboratory at the National Influenza Centre,17 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib17) and modified horse red-blood-cell hamagglutinin inhibition assay in BSL 2 conditions at the National Influenza Centre.18 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib18) Antigens for the assays were produced from the index case's virus isolate. Sera were tested in duplicate by two separate microneutralisation assays done on different days. An individual was deemed to be seropositive for H5N1 antibody if H5N1 neutralising antibody titres of 1:80 or greater were detected for single serum, or four-fold or greater rises for paired sera, and confirmed by horse red-blood-cell haemagglutinin inhibition assay.[14] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib14) and [19] (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib19)
Data collection for H5N1 cases was determined by the Chinese Ministry of Health to be part of a continuing public-health outbreak investigation and exempt from institutional review board assessment. Case two granted permission for data collection on him and his son (case one) for research purposes. The protocol for collection of epidemiological data and serological testing of close contacts was approved by the China CDC institutional review board. Written, signed, informed consent was obtained from 91 adult contacts to participate in the study. Role of the funding source
The study sponsors had no role in the design or conduct of the study, or in the collection, analysis, or interpretation of the data. Hongjie Yu had full access to all data included in the study and is responsible for the integrity of the data and accuracy of data analyses. Yu Wang made the final decision to submit the manuscript for publication. Results
The index case, a 24-year-old male salesman, was well until August, 2007, when he experienced transient chills and sweats once or twice a month. On Nov 24, he developed fever (38·8°C), malaise, and chills, and was treated with oral antibiotics as an outpatient the next day. On Nov 27, he was hospitalised with persistent fever, chills, headache, myalgia, sore throat, cough, and sputum production. On admission, the patient had lymphopenia, moderate thrombocytopenia, and left-lower-lobe pneumonia (table 1 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl1)). A blood culture taken on Nov 28 yielded Salmonella choleraesuis; he was thus treated for bacterial infection. The patient developed progressive dyspnoea, copious frothy sputum production, watery diarrhoea, and pneumonia. Despite administration of broad-spectrum antibiotics, corticosteroids, and mechanical ventilation, the patient died of acute respiratory distress syndrome, disseminated intravascular coagulation, and multiorgan failure on the fifth day in hospital. An endotracheal aspirate obtained on the fifth day of hospitalisation, just before death, was positive for H5N1 by RT PCR and H5N1 virus was isolated.
Table 1.
Clinical features of the two cases
| Index case | Case two | |
|---|---|---|
| General | ||
| Age (years) and sex | 24, male | 52, male |
| Temperature (°C)* (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl1fn1) | 40·1 (40·4) | 38·9 (40·0) |
| Blood counts* (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl1fn1) | ||
| White blood cells (×109 per L) | 7·1 (0·7) | 6·7 (4·0) |
| Lymphocytes (×109 per L) | 0·49 (0·12) | 1·06 (0·5) |
| Platelets (×109 per L) | 88 (37) | 99 (54) |
| Serum biochemistry* (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl1fn1) | ||
| Alanine aminotransferase (U/L) | 17·3 (107·0) | 30·7 (110·4) |
| Aspartate aminotransferase (U/L) | 43·8 (374·0) | 61·5 (84·7) |
| Albumin (U/L) | 36·8 (34·7) | 37·7 (37·7) |
| Creatinine (U/L) | 96·8 (367·1) | 98 (98) |
| Creatine kinase (U/L) | 85 (341) | 138 (138) |
| Lactate dehydrogenase (U/L) | 328 (3036) | 548 (548) |
| Coagulation* (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl1fn1) | ||
| Prothrombin time (seconds) | 16·6 (16·6) | 11·7 (10·06) |
| Activated partial thromboplastin time (seconds) | 87·2 (180·1) | 39 (39·0) |
| Fibrinogen (g/L) | 2·01 (3·28) | 4·4 (4·02) |
| Arterial blood* (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl1fn1) | ||
| PaCO2 (mm Hg) | 23·3 (36) | 27 (28) |
| PaO2 (mm Hg) | 42 (44) | 59 (66) |
| Bicarbonate (mEq/L) | 14·6 (26·4) | 20·1 (19·5) |
| Alveolar-arterial oxygen gradient (mm Hg) | 79 (83) | 92 (94) |
| Other | ||
| Chest radiography | Left lower-lobe infiltrate | Right upper, bilateral lower-lobe infiltrates |
| Gastrointestinal symptoms | More than five episodes of watery diarrhoea without blood or mucus on the night of day 4 and ≥15 episodes on day 5 | Two episodes of watery diarrhoea without blood or mucus on day 3 |
| Complications | Acute respiratory distress syndrome, respiratory failure, cardiac failure, disseminated intravenous coagulation, liver function impairment, renal dysfunction | Respiratory failure, liver dysfunction |
| Treatment | ||
| Mechanical ventilation | Intubation | Mask positive pressure ventilation |
| Corticosteroids | Methylprednisolone 40 mg intravenously twice daily on days 6–9 | Methylprednisolone 40 mg intravenously twice daily on days 3–8 |
| Rimantadine | No | 100 mg orally twice daily on days 3–7 |
| Oseltamivir | No | 75 mg orally daily on day 1 of illness, 150 mg orally twice daily on days 2–6 |
| Passive immunotherapy | No | 2×200 mL transfusion of post-vaccination plasma on day 5 |
| Days from onset to death or discharge | 8, died | 23, discharge |
Case two (the index patient's father), a 52-year-old retired engineer with hypertension, developed fever (38·1°C), chills, and cough on Dec 3. That night he took one dose of oseltamivir (75 mg orally) that had been distributed for chemoprophylaxis to contacts of the index case. The next morning, he was hospitalised with fever, mild thrombocytopenia, and bilateral pneumonia, and treated with levofloxacin, corticosteroids, and oseltamivir (150 mg orally twice daily for 5 days; table 1 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl1)). Rimantadine (100 mg orally twice daily for 5 days) was started on day 3 of his illness. His respiratory status worsened, requiring positive pressure ventilation. On Dec 7, he received two 200 mL transfusions of plasma at 0100 h and 0500 h from a 30-year-old woman who had received two doses of inactivated whole-virion H5N1 vaccine (days 0 and 28) in a phase I clinical trial.20 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib20) Plasma obtained 280 days after the second vaccine dose was negative for hepatitis B virus, hepatitis C virus, and HIV, and was heat-inactivated at 56°C for 10 h (neutralising antibody titres 1:40 against the clade 1 vaccine strain A/Vietnam/1194/2004-RG and 1:20 against case two's virus strain A/Jiangsu/2/2007). The patient's fever resolved that night. A chest radiograph on Dec 12 (day 10) showed improvement in the right upper and bilateral lower lobes (figure 1 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#fig1)). H5N1 virus was isolated from a throat swab collected on day 4 of the patient's illness, and H5N1 viral RNA was detected in throat and stool specimens up to 10 days after the onset of illness. The patient recovered fully and was discharged 22 days after admission.
| http://www.sciencedirect.com.proxy.library.vcu.edu/cache/MiamiImageURL/B6T1B-4S7G10B-1-6/0?wchp=dGLbVlW-zSkWA (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MiamiCaptionURL&_method=retrieve&_udi=B6T1B-4S7G10B-1&_image=fig1&_ba=1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articles)&_cdi=4886&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=8cb7795e90d0de762806e5f09c15b8ff) | Display Full Size version of this image (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MiamiCaptionURL&_method=retrieve&_udi=B6T1B-4S7G10B-1&_image=fig1&_ba=1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articles)&_cdi=4886&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=8cb7795e90d0de762806e5f09c15b8ff) (39K) Display High Quality version of this image (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MiamiCaptionURL&_method=retrieve&_udi=B6T1B-4S7G10B-1&_image=B6T1B-4S7G10B-1-7&_ba=&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articles)&_cdi=4886&_isHiQual=Y&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=8369984dbe3f4c874f8edd561565182c) (212K) |
Figure 1. Improvement of pulmonary lesions in chest radiographs from case two
(A) Bilateral lower-lobe infiltrates on day 4 of illness. (B) Reduction of pulmonary lesions in the right upper and bilateral lower lobes on day 10 of illness.
Complete genomic sequencing showed that the H5N1 viruses isolated from the index case (A/Jiangsu/1/2007) and case two (A/Jiangsu/2/2007) were identical, except for one non-synonymous nucleotide substitution in the NS gene (glutumate to glycine at aminoacid position 82) coding for the NS2 protein. All genes were entirely of avian origin and both isolates were characterised as H5N1 clade 2.3.4 viruses.2 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#bib2) Sequence analyses indicated that these two isolates were highly homologous (sharing 97·2–98·9% homology in aminoacid sequences of the haemagglutinin gene) with viruses isolated from H5N1 cases in southern China. The haemagglutinin receptor-binding site was similar to that of other H5N1 viruses, and a polybasic aminoacid cleavage site (LRERRRKRG) was present. Sequencing of the M2 and neuraminidase genes of both viruses suggested susceptibility to adamantane and neuraminidase inhibitor antiviral drugs.
The index case lived with his mother in an apartment located in an urban area 10 km from his father's home, and rarely shared meals with him. No poultry were raised in the home or neighbourhood, and no live poultry were ever brought home. He had been bitten by a healthy pet dog 25 days before the onset of H5N1 illness and received four doses of rabies vaccine. He had consumed cooked poultry four times at restaurants during the 2 weeks before the onset of illness. No live poultry were present or slaughtered at these restaurants. He did not have any known direct contact with live poultry or ill individuals in the 2 weeks before the onset of illness. 6 days before the onset of illness, he visited a market to purchase vegetables and freshly killed pork with his girlfriend. She reported that the index case had not gone near the area where live poultry were sold and slaughtered in the market, 10 m from the section they had visited.
The index case's father did not raise poultry and had not brought live poultry into the home. He visited a market to purchase vegetables and bean curd 15 days and 8 days before the onset of illness. Live poultry were sold and slaughtered at this market, but the patient denied going near this area, which was 20 m from the vegetable stalls. The patient did not have any known contact with ill individuals except for his son during the 2 weeks before the onset of illness. After the index case became ill, the patient had close contact with him five times, including eating dinner together, providing care, and attending his funeral (table 2 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl2)). He provided unprotected bedside hospital care for the index case between Nov 27 and 29. The longest continuous time he spent caring for his son was 20 h. During this period, the index case had high fever (40·0°C), frequent coughing, extensive sputum production, and frequent episodes of watery diarrhoea. Case two had helped to change his son's soiled clothes and bedsheets, and had cleaned the toilet that had been used to dispose of diarrhoeal stool and a spittoon that contained copious sputum. The patient did not use personal protective equipment until after H5N1 had been confirmed in the index case late on Dec 1. A summary of the patient's exposure to one another is shown in figure 2 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#fig2).
Table 2.
Detailed exposure of case two to the index case before the onset of illness
| http://www.sciencedirect.com.proxy.library.vcu.edu/cache/MiamiImageURL/B6T1B-4S7G10B-1-9/0?wchp=dGLbVlW-zSkWA (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MiamiCaptionURL&_method=retrieve&_udi=B6T1B-4S7G10B-1&_image=fig2&_ba=2&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articles)&_cdi=4886&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=b1c404e85130079511c8d1667c2c9896) | Display Full Size version of this image (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MiamiCaptionURL&_method=retrieve&_udi=B6T1B-4S7G10B-1&_image=fig2&_ba=2&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articles)&_cdi=4886&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=b1c404e85130079511c8d1667c2c9896) (41K) Display High Quality version of this image (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=MiamiCaptionURL&_method=retrieve&_udi=B6T1B-4S7G10B-1&_image=B6T1B-4S7G10B-1-B&_ba=&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articles)&_cdi=4886&_isHiQual=Y&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=b69472d8f6da18f926203c8d2d6a7b63) (431K) |
Figure 2. Timeline of pertinent exposures and dates of onset of illness
100 close contacts of the H5N1 cases were identified and followed up daily for 10 days. Of these, 91 (91%) gave consent for collection of data, completed a questionnaire, and provided serum specimens, including nine (10%) household contacts, five (5%) social contacts, and 77 (85%) health-care workers who cared for the two cases (table 3 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl3)). Eight contacts (the index patient's mother and girlfriend, four family members, one colleague of the mother, and one health-care worker) were exposed to both cases.
Table 3.
Type of exposure and sera collection of 91 close contacts
Data are median (IQR) or n (%).
* Including direct contact (touching), preparation, cooking, and consumption of well-appearing poultry.
† For each of these analyses, data available for one participant only.
The median duration of exposure to at least one of the cases was 7 h (IQR 2–36). 78 (86%) of the close contacts reported taking oseltamivir chemoprophylaxis beginning on Dec 3, and some reported always wearing protective equipment, including surgical masks, N95 respirators, gloves, face shields, glasses, or gowns while caring for the two cases (table 3 (http://www.sciencedirect.com.proxy.library.vcu.edu/science?_ob=ArticleURL&_udi=B6T1B-4S7G10B-1&_user=709070&_coverDate=04%2F07%2F2008&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%239999%23999999999%2399999%23FL A%23display%23Articl#tbl3)). N
If a more transmissible viral strain was emerged in souther China - densely populated - at this point there would be hundreds of thousands of cases, or millions.
Calm down, press!
China is a hot spot these days, Olympic torch permits.
#If you have any other info about this subject , Please add it free.# |
