WHO to send team to Iraq (H5N1 cluster, H2H possible, 30 being tested, 2 others in hospital)

(CP) - It appears H5N1 avian influenza has spread to war-torn Iraq, a most unwelcome twist on the evolving path of this worrisome virus.

A U.S. military laboratory in Cairo confirmed a 15-year-old girl from Kurdistan in northern Iraq who died on Jan. 17 was infected with H5N1 avian flu, Iraqi authorities announced Monday. Earlier testing by the Iraqi national laboratory and another in Jordan concluded she did not have the virus.

H5N1 is also suspected as the cause of death for the girl's 50-year-old uncle, who became ill after nursing the dying teenager. He died last Friday. Confirmatory testing on samples from both is being conducted at Britain's National Institute for Medical Research, a collaborating laboratory for the World Health Organization.

"We're classifying this as a preliminary positive case, which is what we're using to describe the cases in Turkey, so that we can react as if it is a confirmed H5N1 case," WHO spokeswoman Maria Cheng said from Geneva.

"But we'd still like the results to be confirmed by the WHO collaborating centre in the U.K."

There is a possibility this is a case of limited human-to-human spread of the virus, Cheng acknowledged. "Based on the evidence we have right now, I don't think we can rule it out."

"We still don't have a lot of details about the context of these cases; whether or not they both had contact with sick chickens or just how much contact they had. But given that he was said to have taken care of her when she was ill, that certainly does raise our level of concern."

There have been several reported cases of what was thought to be limited, inefficient person-to-person spread, where people caring for an H5N1 case developed infection themselves. To date, the WHO has seen no evidence of the sustained human-to-human transmission.

If confirmed, these will be the first H5N1 human cases recorded in the Middle East. They represent not merely a expansion of the virus's geographic range, but a logistical nightmare for the WHO and sister UN agency the Food and Agriculture Organization, which would have a lead position for any response to outbreaks in poultry.

"What I think is probably most significant with regards to the situation in Iraq is just the security context in which this outbreak would need to be investigated," said Dr. Eric Toner, a senior associate with the Center for Biosecurity at the University of Pittsburgh Medical Center.

Toner noted the WHO teams that responded to the recent H5N1 outbreak in remote eastern Turkey encountered significant hurdles. Blizzards forced the cancellation of flights and poor roads slowed ground travel. But there were no security concerns in Turkey, where officials co-operated fully with the international team of experts.

"Getting people into the Kurdish areas of Iraq has all kinds of new challenges," he said.

A team of four or five WHO experts - epidemiologists, clinicians and a lab technician - is being drawn up. It's hoped they can be on the ground in northern Iraq later this week, "but there is a security situation which is going to make the team getting in and out a bit more difficult," Cheng admitted.

At least 240 foreigners in Iraq have been kidnapped in the past two years, some for ransom, and others, including currently held Canadians James Loney and Harmeet Sooden, for political purposes. At least 40 kidnapping victims have been killed.

"Westerners in general are targets of opportunity for people who use this is a business opportunity and sometimes sell them on to politically motivated groups. It's a very complex, complicated mess," noted Dr. David Fedson, a flu expert and retired academic.

Dr. Richard Waldhorn, a colleague of Toner's and a distinguished scholar at the centre, said from the point of view of the threat of igniting a flu pandemic, densely populated places with avian flu outbreaks - places like Indonesia - continue to pose the highest risk. But from the point of view of mounting a response, Iraq poses unique difficulties for the World Health Organization.

"I think there are worse spots. Epidemiologically worse. (But) I can't think of anything worse politically and mechanically for WHO to navigate," Waldhorn said from Baltimore, where the centre is based.

"With a politically unstable and militarily unstable situation, I can't imagine that would make it any easier for them to conduct their usual investigative work."

How much work there is to be done remains unclear. Iraq has not reported cases of avian influenza to the Food and Agriculture Organization, said Dr. Juan Lubroth, head of the organization's emergency prevention system.

Lubroth said a local consultant who works with the organization has said there don't appear to be outbreaks in commercial poultry operations. But the state of backyard poultry flocks may be a different matter.

Turkish authorities said last week they believe a number of neighbouring countries have unreported outbreaks of H5N1 in poultry. Lubroth said his agency believes that's likely true.

"We highly suspect that there is highly pathogenic (H5N1) avian influenza in the countries neighbouring Turkey, also including Romania and Ukraine, not to forget those. So therefore we've sent out messages of alert to those countries to do better investigations, to do better surveillance and to take on preventive actions so that the disease is not spread further," Lubroth said.

Iraqi health authorities began killing domestic birds in northern Iraq, which borders Turkey, where at least 21 cases of the deadly virus have been detected. Turkey and Iraq also lie on a migratory path for numerous species of birds.

"We regretfully announce that the first case of bird flu has appeared in Iraq," Iraqi Health Minister Abdel Mutalib Mohammed told reporters in the Kurdistan city of Sulaimaniyah, 260 kilometres northeast of Baghdad.

"The results show the infection with the deadly H5N1," he said. "We appeal to the World Health Organization to help us."

The girl, Abdul Qader, died after developing severe pneumonia in the Kurdistan village of Raniya, about 100 kilometres south of the Turkish border and just 24 kilometres west of the border with Iran. She had an aortic aneurysm and a history of cardiac problems. The girl's mother rejected the bird flu results, but acknowledged that a number of her chickens had mysteriously died before her daughter's death.

"My daughter did not die from bird flu," Fatima Abdullah, 50, told The Associated Press. "She did not like chickens nor had anything to do with them. She did not take care of these birds."

Kurdistan Health Ministry official Najimuldin Hassan said 14 people have recently been admitted to local hospitals exhibiting bird flu symptoms, but just two remain in Sulaimaniyah Teaching Hospital suspected of possibly having the disease.

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