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H5N1/H1N1 VIRUS CO-INFECTION - EGYPT: ex SAUDI ARABIA, SUSPECTED,
REQUEST FOR INFORMATION
*****************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Sun 30 Aug 2009
Source: AlMasry AlYoum [in Arabic trans. Hussain Ayoub, paraphrased
and edited]
<http://www.almasryonline.com/portal/pag ... 14&pType=1>


A sample taken from a 28 year-old man who arrived at the port of
Safaga from Saudi Arabia after performing Umrah [pilgrimage] has
tested positive for [both] bird and swine flu [that is, presumably avian
influenza (H5N1) virus and pandemic (H1N1) 2009 virus infections]. He
was immediately detained and held in isolation in a hospital in
Hurghada.

Mohammad Rifai, director-general of preventative medicine, stated that
this case is the 3rd in 2 days. [The other 2 are a 35-year-old Italian
tourist also retained at the hospital in Hurghada and] another
pilgrim, 30 years old, who has been detained in Safaga Central
Hospital. Rifai pointed out that a sample from a 38-year-old citizen
has tested negative.

Another 2 cases have been detained in Mansoura fever hospital on
suspicion of similar illness.

5 cases, including 4 children, suspected of having contracted
"bird flu" infection [presumably avian influenza (H5N1) virus
infection] have been detained in Mansoura Chest hospital.

[Byline: Mohamed Soliman]

--
Communicated by:
ProMED-mail <promed@promedmail.org>

[Does the director-general of preventative medicine mean this case is
the 3rd in 2 days of *dual* infection? Unless both *viruses* were
detected in the patient, not simply positive antibody results, this
would be inconclusive, since Egypt has reported cases of H5N1
throughout 2009, and this person may have had a mild infection before
leaving for Saudi Arabia. Saudi Arabia has reported 285 cases (no
deaths) of H1N1 in 2009 -- see last case count of 22 July in ProMED
ref. below -- but it is also possible that the Egyptian
pilgrim(s) could have caught H1N1 from a pilgrim from another
H1N1-infected country.- Mod.JW]

[If this report is confirmed it raises the prospect of the potential
evolution by genome subunit reassortment of a highly transmissible
influenza virus like the pandemic (H1N1) 2009 virus with the enhanced
virulence of the avian (H5N1) virus. Further information is awaited
confirmatory or not, by laboratory analysis, of the occurrence of dual
infection. - Mod.CP]

[Port Safaga, in the Red Sea Governorate (El Bahr El Ahmar), can be
located on the HealthMap/ProMED-mail interactive map of Egypt at
<http://healthmap.org/r/00KC>. - Sr.Tech.Ed.MJ]

H5N1/H1N1 VIRUS CO-INFECTION - EGYPT (02): ex SAUDI ARABIA, NOT
***************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>


Date: Tue 1 Sep 2009
Source: Youm7 [in Arabic, machine trans., edited]
<http://www.youm7.com/News.asp?NewsID=132676>

The Ministry of Health through the Council of Ministers daily report
on the situation regarding swine flu [pandemic (H1N1) 2009 influenza
virus infection], has now discounted the rumour of [a co-infection]
with avian influenza virus of one of the cases infected with H1N1 type
virus upon his arrival at the port of Safaga from Umrah [pilgrimage to
Saudi Arabia].

The Ministry said that this pilgrim was infected with swine flu
[pandemic (H1N1) 2009 virus] in addition to a common [seasonal] flu
and not bird flu [avian H5N1 influenza virus]. [Previously it was
suggested that the patient was co-infected with H1N1 and H5N1 viruses.
- Mod.CP]. This patient's health is good and his condition stable. He
will leave hospital within 2 days after treatment. This emphasizes the
lack of any potential interaction between a mutant avian H5N1 virus in
Egypt and an H1N1 strain.
[Byline: Mona Zia]
--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

******
Date: Wed, 2 Sep 2009 11:44:45 -0500 [12:44:45 EDT]
From: Jason Garner <jasonlgarner@gmail.com>

I would like to pass on information just released by both PLoS and the
NIH regarding interaction of the pandemic A(H1N1) with co-infections
of seasonal flu viruses.

A University of Maryland/NIH study, using ferret animal models,
suggests that co-infections of A(H1N1) with seasonal flu viruses do
not produce chimeric or reassortant viruses. Said another way, the
A(H1N1) outcompetes seasonal viruses, possibly demonstrating the
pandemic strain is not under biological pressure and is perhaps more
efficiently communicable.

However, with regard to the H5N1-A(H1N1) co-infections reported
recently, there is no data to suggest these latest findings could
apply to H5N1 co-infections. In light of the characteristic that HPAI
H5N1 has been shown to be a "dead-end" infection in humans, it could
possibly be out-competed by a more robust strain such as A(H1N1)
rather than being a player in a recombination event.

Link to the NIH study results summary:
<http://www.nih.gov/news/health/aug2009/niaid-31.htm>

--
Jason L Garner
Senior Molecular Biologist
Global Influenza Surveillance

*******
Date: Wed, 2 Sep 2009
From: Mary Marshall <mjm2020@googlemail.com>
Source: ScienceInsider
<http://blogs.sciencemag.org/scienceinsi ... eport.html>

Specious Report of Bird and Swine Flu Co-infection
--------------------------------------------------
An Egyptian news story that is starting to receive worldwide attention
about a nightmare swine flu/bird flu co-infection is inaccurate,
according to officials at the U.S. Centers for Disease Control and
Prevention (CDC).
On 30 August, the well-regarded Egyptian newspaper Almasry reported
that an Egyptian man who returned from a religious pilgrimage to Saudi
Arabia had tested positive for both the highly lethal bird flu virus,
H5N1, and the novel H1N1 strain that is the cause of the swine flu
pandemic.

This was the first such report of a co-infection with the two viruses,
which many researchers fear because the mix could create a new virus
that has the virulence of bird flu, which does not move easily between
humans, and the highly transmissible swine flu.

The Egyptian report was picked up yesterday by the widely read
electronic surveillance system ProMED. Although the ProMED moderators
raised many questions about the story, it remained unclear whether it
was accurate. According to Nancy Cox, head of the CDC?s influenza
division, there is no evidence that this man is infected with both
viruses. ?Our reliable sources indicate that this report is
incorrect,? Cox told ScienceInsider in an e-mail. Apparently, tests
have shown that the man is co-infected with the pandemic H1N1 and the
seasonal H3N2 virus. ?There will be follow up testing to confirm,?
according to Cox. As many as 5% [1 in 20] people who develop flu
symptoms are infected with 2 different influenza viruses.
[By Jon Cohen]

[The statement from the Egyptian Ministry of Health denies the
earlier report that a pilgrim returned from Saudi Arabia was infected
with both pandemic H1N1 influenza virus and an avian (H5N1) influenza
virus strain.
It now appears that the co-infection is believed to be between 2 low
virulence viruses (pandemic H1N1 & H3N2) and *not* between a highly
virulent, poorly transmissible, virus (pandemic H1N1) and a highly
transmissible strain of low virulence (H5N1) which might, as a result
of genetic interaction, generate a highly transmissible and highly
virulent strain. The consequences of the interaction as a result of
co-infection of 2 highly transmissible viruses of low to moderate
virulence, as in the present case, are unclear but less threatening.

A question arises over the accuracy of the diagnostic procedures
supporting the claim of co-infection. A highly relevant comment on the
original report from Egypt has been received from Jason L Garner,
Senior Molecular Biologist, Global Influenza Surveillance
(<jasonlgarner@gmail.com>) and is reproduced in full below.

"This is a worrisome event.
1) My 1st and obvious question is how were these results obtained? DFA
[direct fluorescence antibody]? RT-PCR? rRT-PCR?
2) Also, what type of specimen was used in the assay, such as NP
[nasopharyngeal], nasal wash, throat swab, virological culture? Unlike
seasonal or pandemic A (H1N1) flu, the preferred method for collecting
HPAI H5N1 specimens is via throat swab, and the others either NP or
nasal wash. From a molecular standpoint HPAI H5N1 is difficult to
discern even in sensitive rRT-PCR assays, unless an original throat
swab and/or a cultured isolate was employed.
3) If it was obtained with cultured isolate, wouldn't one strain
perhaps out-compete the other as is usually the case with seasonal H1
and H3 viruses?
4) Are there substantial differences in LPAI and HPAI gene segment
targets to discern with assay used?
5) Lastly, how and by what methods, if any, were potential
contamination variables controlled?
Very interested to learn more."

A response from the Egyptian Ministry of Health would be welcomed. -
Mod.CP/JW]

H5N1/H1N1 VIRUS CO-INFECTION - EGYPT (02): ex SAUDI ARABIA, NOT, CORRECTION
***************************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>


Date: 3 Sep 2009
From: ProMED-mail <promed@promedmail.org>


Both the Egyptian Ministry of Health & CDC now concur that the
dual-infected patient hospitalized in Egypt did not have avian (H5N1)
together with pandemic (H1N1) 2009 virus (see 1st ProMED ref. below).
The co-infection was with seasonal H3N2 virus.

I introduced an error into Mod.CP's comment. The relevant sentence
should read
"It now appears that the co-infection is believed to be between 2 low
virulence viruses (pandemic H1N1 & H3N2) and *not* between a highly
virulent, poorly transmissible, virus (pandemic H5N1) and a highly
transmissible strain of low virulence (H1N1)..."

I regret adding to the confusion.
--
Jack Woodall (Mod.JW)
Assoc.Ed. ProMED
<woodall@promedmail.org>