Egypt new epicentre
With 119 confirmed cases
between March 2006 and December 2010, Egypt ranks second among countries
reporting human H5N1 influenza virus infections. In 2009–2010, Egypt
reported 68 new human cases and became the new epicentre for H5N1
Writing in PLoS One online open access journal, researchers from St Jude
Children’s Hospital in Memphis and Egypt’s National Research Center in
Cairo explore the epidemiology of H5N1 in Egypt and provide an analysis
of some of the genetic isolates of the virus with a view to seeing if
these mutations are responsible for the lower mortality rate in humans
in Egypt compared to other countries where the virus is prevalent.
The authors write that there is some concern that because the Egyptian
isolates seem to be less virulent than that elsewhere, they are becoming
more adapted to humans.
CIDRAP news summaries the epidemiology in the report as follows: Egypt
had 119 human H5N1 cases from 2006 through 2010, with 40 deaths (CFR,
34%), the report says. In 2006 the cases peaked in the spring, and in
the ensuing 4 years they peaked in the winter and spring. There were
three family clusters totalling seven cases during that time.
Sixty-two per cent of the patients were under age 18, and 60% were
female. The mean age for all patients was 10 years, with a range of 1 to
75 years. The young age distribution could reflect Egypt's demographics
or children's level of contact with poultry, the authors say. They also
note that women typically play the lead role in tending backyard
poultry, perhaps explaining the burden of cases in females, but this
Bird flu in Egypt –
winter takes its toll
The following confirmed cases of human infection with avian
influenza A (H5N1) virus in Egypt have been reported since
January this year.
- A 26-year-old female from Dakahlia Governorate developed
symptoms on 18 January and was hospitalised on 23 January. She
recovered and was discharged on 7 February.
- FATAL: A 45-year-old male from Menofia Governorate developed
symptoms on 20 January and was hospitalised on 26 January. He
died on 5 February.
- A 32-year-old woman from Sharkia Governorate developed
symptoms on 10 February and was hospitalised on 14 February. She
died on 3 March.
- A 4-year-old male from Damiata Governorate developed symptoms
on 14 February and was hospitalised on 16 February. He was
reported in a stable condition.
- A 2-year-old boy from Kafr Elsheikh Governorate developed
symptoms on 18 February and was hospitalised on 20 February. He
was reported in a good general condition.
- FATAL: A 17-year-old girl from Dakahlia Governorate developed
symptoms on 24 February and was hospitalised on 26 February. She
died on 28 February.
- A 17-year-old girl from Behira Governorate developed symptoms
on 27 February and was hospitalised on 1 March. She was reported
in a stable condition.
- A 4-year-old male from Behira Governorate developed symptoms
on 5 March and was hospitalised on 7 March. He recovered and was
discharged on 12 March.
- A 28-year-old female from Giza Governorate developed symptoms
on 8 March and was hospitalised on 10 March. She was reported in
a stable condition.
- FATAL: A 32-year-old male from Suez Governorate developed
symptoms on 8 March 2011, was hospitalised on 12 March and died
on 13 March.
- FATAL: A 20-year-old female from Behaira Governorate developed
symptoms on 14 March and was hospitalised on 19 March. She was
in a critical condition and died on 28 March.
- A 55-year-old female from Behaira Governorate developed
symptoms on 20 March and was hospitalised on 22 March. She
recovered and was discharged on 5 April.
- A one-year-old male from Fayoum Governorate developed symptoms
on 20 March and was hospitalised on 28 March. He was reported in
a stable condition.
- A two-year-old female from Menofeya Governorate developed
symptoms on 26 March and was hospitalised on 27 March. She was
reported in a stable condition.
- FATAL: A 29-year-old man from Fayoum Governorate Wadi Elrian
area, developed symptoms on 1 April and was hospitalised on 4
April. He died on 7 April.
- A one-and-a-half-year-old boy from Fayoum Governorate,
Sennores District, developed symptoms on 9 April and was
hospitalised on 11 Apr 2011. He was reported in a stable
Of the 141 total cases confirmed to date (11 April 2011) in
Egypt, 46 have been fatal.
The fatality rate increased with
age and was three times as high in females as in males, the
investigators found. The CFR ranged from 4% for children under 5 to 10%
for 5- to 9-year-olds and 53% for 10- to 18-year olds. Adults up to age
49 had a 61% CFR, and the rate was 75% for older adults. The rate for
females was 47%, versus 15% for males, a significant difference.
The CFR also varied considerably by year and was particularly low in
2009, at 10%, before bouncing up to 45% in 2010, the authors note. Most
of the cases in 2009 were in children under age 5, but a regression
analysis showed that mortality was significantly lower in 2009 than in
other years even when the different age distribution was taken into
Early hospitalisation was found to be a key factor in survival. The CFR
for patients who were hospitalised within the first 2 days was 8%,
versus 54% for those who were hospitalised later, a significant
The authors caution that the overall 34% CFR may be an overestimate,
because the rate of unrecognised cases is unknown.
The researchers found that the pattern of H5N1 cases in humans tends to
mirror the pattern in poultry, both in frequency and severity. “For
instance, a decrease in human case-fatality rate in 2009 was accompanied
by an observed decrease in mortality among poultry,” they write.
The researchers say several genetic sublineages of H5N1 clade 2.2.1 have
been found in Egypt. Three of these are still circulating. However it
appears that no specific lineages are present only in humans. There has
been no host-adaption mutation observed “which suggests that the main
transmission route of H5N1 in Egypt is still contact with infected
birds, just as observed in the rest of the world.”
The authors point out that they were not able to confirm that lower
pathogenicity of the viruses is the main reason for increase or decrease
in the mortality rate among humans in Egypt.
The researchers says they are concerned about the potential of H5N1
viruses circulating in Egypt to become more adapted to human-to-human
transmission because these new viruses are less virulent and may be
causing asymptomatic infections especially among adults.
They point out that there is an “urgent need to conduct more
epidemiologic studies in Egypt and other endemic areas to enhance our
understanding of incidence, prevalence, and determinants of human
infections with avian influenza.”
Ref: Kayali G et al, The Epidemiological and Molecular Aspects of
Influenza H5N1 Viruses at the Human-Animal Interface in Egypt, PLoS ONE
Landmark agreement improves global preparedness for influenza
In a major breakthrough for the way the world deals with
future influenza pandemics, the World Health Organisation has
brokered an international agreement that will see the open
sharing of vital information to ensure more effective and
efficient access to essential influenza vaccines and
medications, particularly for lower-income countries.
Following negotiations which began in November 2007 amid
concerns that the avian influenza (H5N1) virus in South- East
Asia could become a human pandemic, and after a final week of
tough negotiations in April this year, an openended
working-group meeting of WHO Member States successfully agreed
upon a Framework that ensures that in any future influenza
pandemic, virus samples will be shared with partners who need
the information to take steps to protect public health.
The working-group meeting was convened under the authority of
the World Health Assembly and coordinated by the World Health
The new Framework includes certain binding legal parameters for
WHO, national influenza laboratories around the world and
industry partners in both developed and developing countries
that will strengthen the effectiveness of how the world responds
with the next flu pandemic. By making sure that the roles and
obligations among key players are better established than in the
past – including through the use of contracts – the Framework
will help increase and expedite access to essential vaccines,
antivirals and diagnostic kits, especially for lower-income
In addition, the Framework will also put the world in a better
position for seasonal influenza and potential pandemic threats
such as the H5N1 virus, because some key activities will begin
before the next pandemic, such as greater support for
strengthening laboratories and surveillance, and partnership
contributions from the industry.
During an influenza outbreak, knowing the exact makeup of the
virus is critical for monitoring the spread of the disease, for
knowing the potential of the virus to cause a pandemic and for
creating the life-saving vaccines as well as other technological
benefits. However, developing countries often have limited
access to these vaccines for several reasons: they often do not
have their own manufacturing capacity, global supplies can be
limited when there is a surge in demand as is seen during
pandemics, and vaccines can often be priced out of the reach of
The new Framework will help ensure more equitable access to
affordable vaccines and at the same time, also guarantee the
flow of virus samples into the WHO system so that the critical
information and analyses needed to assess public health risks
and develop vaccines are available.
“This has been a long journey to come to this agreement, but the
end result is a very significant victory for public health,”
said Dr Margaret Chan, director-general of the WHO. “It has
reinforced my belief that global health in the 21st century
hinges on bringing governments and key stakeholders like civil
society and industry together to find solutions.”
The legal regimes will address clear roles and responsibilities
of WHO, national labs and vaccine and pharmaceutical
“The framework provides a much more coherent and unified global
approach for ensuring that influenza viruses are available to
the WHO system for monitoring and development of critical
benefits such as vaccines, antiviral drugs and scientific
information while, at the same time, ensuring more equitable
access to these benefits by developing countries,” said Dr Keiji
Fukuda, assistant directorgeneral of Health Security and
Environment at WHO.
The agreed upon framework will be presented to the World Health
Assembly in May this year for its consideration and approval.
WHO document archive
WHO Pandemic Influenza Preparedness
of upload: 10th Jul 2011