EPIDEMIOLOGY OF INFLUENZAVIRUS A (H₅N₁)

Table of contents :

• in 1997 : 18 cases (6 deaths) ranging in age from 1 to 60 years, had gastrointestinal symptoms, hepatitis, renal failure, and pancytopenia. Clinical presentation was that of an influenza-like illness with evidence of pneumonia in 7 patients. All 7 patients > 13 years had severe disease (4 deaths), whereas children 5 years or younger had mild symptoms with the exception of one who died with Reye's syndrome associated with intake of aspirin. Gastrointestinal manifestations, raised liver enzymes, renal failure unrelated to rhabdomyolysis, and pancytopenia were unusually prominent. Factors associated with severe disease included older age, delay in hospitalisation, lower-respiratory-tract involvement, and a low total peripheral white blood cell count or lymphopenia at admission. An H₅-specific RT-PCR was useful for rapid detection of virus directly in respiratory specimens. A commercially available EIA was more sensitive than direct immunofluorescence for rapid viral diagnosis. Direct immunofluorescence with an H₅-specific monoclonal antibody pool was useful for rapid exclusion of H₅-subtype infection^ref. The kinetics of the antibody response to the avian virus in H₅N₁-infected persons was similar to that of a primary response to human influenza A viruses; serum neutralizing antibody was detected, in general, >/=14 days after symptom onset^ref. > 1.4 million chickens and other birds in the open-air markets of Hong Kong were slaughtered in 3 days by trained government workers (GWs), most of whom wore protective masks, gloves, and gowns. Although exposure to live poultry was associated with human illness, no cases were documented among poultry workers (PWs). To evaluate the potential for avian-to-human transmission of H₅N₁, a cohort study was conducted among 293 Hong Kong GWs who participated in a poultry culling operation and among 1525 PWs. Paired serum samples collected from GWs and single serum samples collected from PWs were considered to be anti-H₅ antibody positive if they were positive by both microneutralization and Western blot testing. Among GWs, 3% were seropositive, and 1 seroconversion was documented. Among PWs, approximately 10% had anti-H₅ antibody. More-intensive poultry exposure, such as butchering and exposure to ill poultry, was associated with having anti-H₅ antibody^ref. Avian-to-human transmission of influenza viruses is believed to be infrequent because of host barriers to infection, such as cell receptor specificities, and because the acquisition by avian viruses of the ability for human-to-human transmission requires either genetic reassortment with a human influenza strain or genetic mutation^ref. However, a cohort study of household and social contacts of Hong Kong H₅N₁ case-patients found evidence, although limited, for human-to-human transmission. By use of a combination of serologic assays, 6 of 51 household contacts, 1 of 26 tour group members, and none of 47 coworkers exposed to H₅N₁-infected persons were positive for H₅ antibody. One H₅ antibody-positive household contact, with no history of poultry exposure, provided evidence that human-to-human transmission of the avian virus may have occurred through close physical contact with H₅N₁-infected patients. In contrast, social exposure to case patients was not associated with H₅N₁ infection^ref. Further evidence was provided by a study of healthcare workers (HCWs), which found that significantly more HCWs exposed to patients with H₅N₁ infection were seropositive for H₅ antibody than nonexposed HCWs (8 (3.7%) of 217 exposed vs. 2 (0.7%) of 309 nonexposed HCWs (P=.01)); 2 HCWs seroconverted after exposure to H₅N₁-infected patients, in the absence of known poultry exposure^ref. These 2 studies provided the first evidence, although limited, of human-to-human transmission of H₅N₁ viruses of purely avian origin.
• in February 2003 : 2 cases (1 death). Waterfowl are the natural reservoir of all influenza A viruses, which are usually nonpathogenic in wild aquatic birds. However, in late 2002, outbreaks of HPAI H₅N₁ caused deaths among wild migratory birds and resident waterfowl, including ducks and flamingos^ref, in 2 Hong Kong parks. Several thousand chickens were slaughtered. 2 members of a same family who returned to their home in Hong Kong on 8/2 after being exposed to chickens in Fujian province, mainland China, during the Chinese New Year were affected. The 8-year-old daughter died on 4/2 whilst the family was in Fujian and the 33-years-old father of the family developed respiratory symptoms on 7 Feb whilst in Fujian : he was admitted to hospital in Hong Kong on 11/2 with pneumonia and died on 17/2. Influenza A (H₅N₁) was isolated from post-mortem specimens on 20/2. The man´s 9 year old son also became unwell whilst in Fujian province : he was admitted to hospital in Hong Kong SAR on 12/2 with pneumonia. Influenza A (H₅N₁) was isolated from 2 nasopharageal aspirates taken from the boy on 19/2. The mother recovered from what was thought to have been a parainfluenza infection. The mother and children were in mainland China for 14 days; the father for 9 days. Antigenic analysis of the new avian isolates showed a reactivity pattern different from that of H₅N₁ viruses isolated in 1997 and 2001. This finding suggests that significant antigenic variation has recently occurred among H₅N₁ viruses. In contrast to H₅N₁ viruses isolated from humans during the 1997 outbreak in Hong Kong, A/Hong Kong/213/03 (HK213; H₅N₁) retained several features of aquatic bird viruses, including the lack of a deletion in the neuraminidase stalk and the absence of additional oligosaccharide chains at the globular head of the hemagglutinin molecule. It demonstrated weak pathogenicity in mice and ferrets but caused lethal infection in chickens. The original isolate failed to produce disease in ducks but became more pathogenic after 5 passages. Taken together, these findings portray the HK213 isolate as an aquatic avian influenza A virus without the molecular changes associated with the replication of H₅N₁ avian viruses in land-based poultry such as chickens. This case challenges the view that adaptation to land-based poultry is a prerequisite for the replication of aquatic avian influenza A viruses in humans^ref. When mallards were inoculated with antigenically different H₅N₁ influenza viruses isolated between 1997 and 2003, the new 2002 avian isolates caused systemic infection in the ducks, with high virus titers and pathology in multiple organs, particularly the brain. Ducks developed acute disease, including severe neurological dysfunction and death. Virus was also isolated at high titers from the birds' drinking water and from contact birds, demonstrating efficient transmission. In contrast, H₅N₁ isolates from 1997 and 2001 were not consistently transmitted efficiently among ducks and did not cause significant disease. Despite a high level of genomic homology, the human isolate showed striking biological differences from its avian homologue in a duck model. This is the first reported case of lethal influenza virus infection in wild aquatic birds since 1961^ref.

• South Korea, which had never reported the disease previously : 19 000 birds out of 24 000 died of avian flu between 5 and 11 Dec 2003 at a farm in Yangsan, Eumsung district, Chungbuk province, about 300 km south of Seoul, and 5 000 that had not died from the disease were slaughtered; roughly 900 000 more chickens and ducks at around 30 farms within a 3 km (1.9 mile) radius of the farm would be killed. Since the virus first hit South Korea on 10 Dec 2003 (first official notification on 12 Dec 2003) cases have been reported at 19 farms nationwide and about 4.5 million chicken and ducks were culled of the country's total population of 108 million : affected farms have been quarantined but, after initial success, a further 88 000 birds were slaughtered in mid-January 2004 after a renewed outbreak. Ducks and other migratory birds were the most likely source of the H₅N₁ outbreak among poultry in South Korea : it first invaded ducks in the central city of Cheonan around October 2003. South Korea's livestock industry makes up around 0.4% of the country's gross domestic product. South Korea imported 88,283 tons of poultry between January and November last year : almost 40,000 tons came from Thailand. The outbreak has prompted South Korean consumers to stop eating poultry, and exports of chickens and chicken meat to Japan, Hong Kong, and China have been halted, dragging the chicken meat prices down by 40% to 611 won (USD 0.522)/kg after the outbreak was reported, but have jumped to 1.669 won (USD 1.426)/kg due to tight supplies, triggered by a mass poultry slaughter and import bans. Local feed production for poultry in January also dropped 11.5% from a year earlier to 288 407 tonnes. Test results showed that South Korea's bird flu gene types are identical with that found in Japan but are different from that found in Thailand, Vietnam, and Laos and accordingly causes of the cases are suspected to be different. On Feb 7 South Korea, began culling 291 242 chickens and ducks after 16 new bird flu outbreaks (8 duck farms, 7 chicken farms, and 1 chicken-and-duck mixed farm) were discovered :
• Chnonam Province, Naju city / 1
• Chungbuk Province, Eumsung district / 3
• Chungbuk Province, Jincheon district / 1
• Chungnam Province, Cheonan city / 5
• Chungnam Province, Asan city, south of Seoul / 1
• Kyongbuk Province, Kyongju city / 2
• Kyonggi Province, Icheon city / 1
• Kyongnam Province, Yangsan city / 1
• Ulsan Metropolitan, Ulju district / 1
Another case was reported on Mar 20 (the first new case since 5 Feb 2004) in 16 000 chickens (authorities are also recalling 1570 chickens that have already been distributed to a slaughterhouse south of Seoul) in a farm in Yangju, Kyonggi Province : 400 000 chickens and ducks at 20 farms within a 3-km (1.9-mile) radius of the affected farm would be destroyed and poultry farms within a radius of 30 km (19 miles) to 40 km (25 miles) would be checked twice a day by telephone for new outbreaks. Chicken deaths have been reported since 4 Mar 2004 in Yangiu but had been attributed to a liver disease. In a separate case, the ministry reported that 1 magpie (out of 99 captured and tested) was found to have died of the avian flu in the southern city of Yangsan, South Kyongsang Province, where an outbreak was reported in January 2004. But it was not expected to pose a significant threat, as the incubation period was short in magpies. The last case of the disease was confirmed on 21 Mar 2004^ref.
318 workers were injected with oseltamivir when they were engaging in the slaughter : on Feb 24, 2006, it was revealed that 4 workers, engaged in slaughter of poultry when bird flu was spreading in the country in 2004, have been asymptomatically infected with the H₅N₁ strain of bird flu after series of blood tests made by (South) Korea Center for Disease Control and Prevention (KCDC ) and the United States Center for Disease Control and Prevention (CDC). Moreover, the disease control authorities are conducting antibody tests on serum samples that have been collected from the 1,600 local people who contacted disease poultry in 2004. A total of 19 separate outbreaks affected 392 poultry farms from December 2003 to March 2004, resulting in the culling of 5.28 million birds^ref. The virus responsible for the outbreaks in South Korea and Japan belongs to the V genotype of H₅N₁ avian influenza virus, whereas the predominant virus in East Asia belongs to the Z genotype. However, this is unlikely to be a relevant factor in human susceptibility to infection, since these genotypes are reassortants which differ only in the origin of their NA genome subunit
Some 1000 out of 1200 ducklings died at a poultry farm in Dopyung-Dong, Jeju Island on 1 Nov 2004. About 10 died at the same farm on 21 Oct 2005 but tested negative for avian influenza.
• Vietnam, which has never reported the disease previously : to better understand the extent of transmission of avian influenza viruses (AIV) to humans in Asia, we conducted a cross-sectional virologic study in live bird markets (LBM) in Hanoi, Viet Nam, in October 2001. Specimens from 189 birds and 18 environmental samples were collected at 10 LBM. 4 influenza A viruses of the H₄N₆ (n = 1), H₅N₂ (n = 1), and H₉N₃ (n = 2) subtypes were isolated from healthy ducks for an isolation frequency of over 30% from this species. 2 H₅N₁ viruses were isolated from healthy geese. The hemagglutinin (HA) genes of these H₅N₁ viruses possessed multiple basic amino acid motifs at the cleavage site, were HP for experimentally infected chickens, and were thus characterized as HP AIV. These HA genes shared high amino acid identities with genes of other H₅N₁ viruses isolated in Asia during this period, but they were genetically distinct from those of H₅N₁ viruses isolated from poultry and humans in Viet Nam during the early 2004 outbreaks. These viruses were not highly virulent for experimentally infected ducks, mice, or ferrets. These results establish that HP H₅N₁ viruses with properties similar to viruses isolated in Hong Kong and mainland China circulated in Viet Nam as early as 2001, suggest a common source for H₅N₁ viruses circulating in these Asian countries, and provide a framework to better understand the recent widespread emergence of HP H₅N₁ viruses in Asia^ref. A very crude plotting of HPAI H₅N₁ outbreaks in a map of Indochina shows a nice progression of dates beginning in the mountains bordering Thailand and Laos and following the Mekong and Mae Nam Chao Phraya waterways. There does seem to be a nidus in the mountains, but my personal bias (pirate ancestors!) leads me to wonder whether there is a handy mountain pass at 100°E and 20°N through which poultry might be smuggled. The problem began at  the end of October 2003 and Vietnamese authorities became more concerned after 70,000 chickens abruptly died on farms in the southern provinces of Long An and Tien Giang provinces in southern Vietnam, > 700 miles from Hanoi (Ho Chi Minh city). The Vietnamese government decided to kill all chickens in a 3-km range around epidemic areas and has banned  movement of all chickens within a 10-km range of the epidemic areas. To date, the virus has been reported from 2570 communes in 57 of the country's 64 provinces, with outbreaks in 445 separate locations : since 23 Dec 2003 (but first official notification on 9 Jan 2004 !), 38.1 million poultry stock of the Vietnam's > 200 million (15%; not a major exporter) have either died or been destroyed because of the disease (Hanoi has culled some 500,000 chickens).
• Location / No. of outbreaks
• An Giang / 143
• Bac Lieu / 21
• Ben Tre / 60
• Bình Dinh / 14
• Bình Duong / 19
• Ca Mau / 28
• Can Tho / 17
• Cao Bang / 1
• Da Nang / 23
• Dac Lac / 27
• Dien Bien / 8
• Dong Nai / 4
• Dong Thap / 73
• Ha Nam / 62
• Ha Tay / 51
• Hai Duong / 65
• Hung Yen / 22
• Kien Giang / 8
• Lai Chau / 17
• Lam Dong / 8
• Long An / 152
• Phu Tho / 57
• Quang Nam / 22
• Quang Ngai / 3
• Soc Trang / 24
• Son La / 13
• T. Thien Hue / 14
• Tay Ninh / 22
• Thai Nguyen / 27
• Thanh Hoa / 42
• Tien Giang / 91
• Tong so / 35
• Tra Vinh / 10
• Vinh Long / 42
• Vinh Phuc / 33
• Yen Bai / 24

Total 1282
No new outbreak was reported in poultry since 26 Feb 2004. An isolated outbreak of H₅N_non-1 was found at the end of April 2004 on a farm in Mekong, Cao Lanh township, in the province of Dong Thap (Mekong Delta rea, south Viet Nam, bordering Cambodia on the north), and was successfully contained. An analysis of 10,000 samples from throughout Viet Nam showed lots of these samples were positive for H₅N_? virus. Reports indicate that pigs have also been infected : preliminary tests found the bird flu virus in the nasal swabs of pigs and ducks in Hanoi. The price of already more expensive animal protein sources (e.g. fish) rose by a further 20-30%, placing them well beyond the reach of many of the poorer consumers. The H₅N₁ outbreak in humans in Vietnam apparently began in October 2003, when children from several villages near Hanoi in southern Vietnam began falling ill with severe respiratory infections. 5 Jan 2004: Health authorities in Viet Nam inform the WHO office in Hanoi of an outbreak of severe respiratory illness in 11 previously healthy children hospitalized in Bach Mai Hospital, the state-run infectious diseases center in Hanoi, with the most recent hospital admission on 4 Jan 2004. 7 cases were fatal and 2 patients remain critically ill. A 12th case, a sibling of one of the Hanoi cases, died of a respiratory illness in  provincial hospital. Included in this report are 6 children, aged 9 months to 12 years, who died in a Hanoi hospital of respiratory illness of unidentified cause between 31 Oct and 30 Dec 2003. For the first 5 cases, no samples are available for analysis. Samples are available for the 6th case, a 12-year-old girl who was admitted to hospital on 27 Dec and died 3 days later. All of these cases were identified retrospectively based on hospital records. 11 Jan 2004: Since the 5 Jan report, Vietnamese officials have identified 2 further cases of severe respiratory illness (another child and the first adult), bringing the total since the end of October 2003 in Hanoi's hospitals to 13. Tests on samples from 2 fatal cases in Viet Nam (12 year old girl and 10 year old boy), performed by Hong Kong's National Influenza Centre, confirm infection with the H₅N₁ AI virus strain. 27 patients have been laboratory confirmed to have been infected with H₅N₁, and among them 20 have died:
• 7 children, including 5 in Hanoi
• 5 from the south of the country : an 8-year-old girl remains hospitalized in Ho Chi Minh City.
• in the south of the country
• a 4-year-old boy who fell ill on 22 Dec 2003, was hospitalized in Hanoi on 29 Dec 2003, has fully recovered and been discharged from hospital
• a 8-year-old girl from Ha Tay province hospitalized since 15 Jan who died on Sat 17 Jan 2004
• a 13-year-old boy from Hanoi admitted to the Paediatric Hospital No. 2 on 19 Jan with respiratory ailments but immediately transferred to Hanoi hospital for treatment, died on Thu 22 Jan 204.
• a 30-year-old woman, mother of a diseases child
• a man was hospitalized in Hanoi with a severe respiratory illness on 7 Jan and died on 12 Jan, while the wife has fully recovered.
• his 2 sisters, aged 23 and 30 in Thai Binh province, 110 km (70 miles) southeast of Hanoi, were admitted to hospital on 13 Jan 2004 and died on 23 Jan. Laboratory tests received over the weekend have confirmed AI A (H₅N₁) virus infection in the sisters : their viruses have been fully sequenced and contain no human influenza genes. However, this is not definitive proof that person-to-person transmission has not occurred : the results of analysis of the structure of the HA protein of the 1918 pandemic influenza virus led to the conclusion that mutation alone is sufficient to explain the acquisition of human transmissibility. Neither the man nor his wife was tested. WHO considers that limited human-to-human transmission, from the brother to his sisters, is one possible explanation.
The family members gathered in late December 2003 to prepare for the man's wedding on 3 Jan 2004. Both the man and one sister are reported to have handled ducks while preparing a meal on 4 Jan. However, the investigation failed to reveal any direct contact with poultry for the man's other sister and his wife. In the absence of evidence of direct exposure to poultry in these 2 cases, WHO epidemiologists are considering various alternative explanations. Both sisters are known to have provided health care for their brother prior to his hospitalization, and would thus have had opportunities for close exposure. Direct human-to-human transmission following this close exposure is thus one possible explanation. However, contact with an infected bird, or some other environmental source of the virus, is another possible route of infection that has not been ruled out. Outbreaks of H₅N₁ in poultry are widespread in Viet Nam. Local authorities report that no other family members or wedding guests developed an illness. No illness has been detected in members of the community where the wedding was held, or in health staff involved in care of these cases. Le Thi Sang lost her 3 children after the family served 66 pounds of chicken at her son's wedding. Her 2 daughters tested positive for bird flu, while her son died of similar symptoms. Despite her loss, Sang still buys poultry a couple times a week and insists her children were not infected with AI. "My son and daughter died of pneumonia, while the other daughter died of stomach [bleeding]," said Sang, 58, on Feb 2005. "It's not bird flu."
• a 17-year-old woman died on Tue 27 Jan 2004
• a 19-year-old man who has recovered
• a 20-year-old woman who remains
• a 18-year-old man who died on 2 Feb 2004 at a hospital in Ho Chi Minh City. He is the country's first confirmed case from the Central Highlands area.
• a 16-year-old woman from Soc Trang province died on Tue 3 Feb 2004
• a 6-years-old girl died in Ho Chi Minh City on 3 Feb 2004
• a 24-year-old man died in Ho Chi Minh City on 3 Feb 2004
• a 27 year old man from southern Binh Phuoc province and believed to have caught the disease at his family's chicken farm died on Feb 9 2004
• a 23 year old man from central Lam Dong province is in hospital in Ho Chi Minh City in a stable condition
• a 19 year old man who had been hospitalized in Ho Chi Minh City died on Feb 12 204
• a young man from Ho Chi Minh City (16 Feb 2004)
• a 15-year-old boy was admitted to hospital on 9 Feb 2004 (confirmed on Feb 17) with fever, coughing, and shortness of breath in northern Thanh Hoa province. The boy's family raises no poultry, and says he did not come in contact with birds, although his neighborhood did experience a bird flu outbreak
• a 3-year-old boy from Lam Dong Province died on Feb 18
• a 16-month-old baby girl from Dong Nai Province hospitalized since Mon 16 Feb 2004 in Ho Chi Minh City remains in stable condition.
• a 12-year-old boy from southern province of Tay Ninh, an ethnic Cham minority, was admitted to a hospital in Tay Ninh province, 60 miles northwest of Ho Chi Minh City, on March 13 suffering from diarrhea and high fever, developed a serious lung infection and died 2 days later. The boy's family had eaten their sick chickens about 5 days before the boy came down with the illness on March 10
After a review of laboratory information held on cases of influenza A/H₅ by the Ministry of Health of Vietnam and the WHO Country Office Vietnam, 1 case has been reclassified from confirmed to probable. This individual had a high titre for H₅ antibodies on sera collected 15 days after onset using the microneutralization test. 271 suspected cases from 36 cities and provinces : 38 have died, 107 remained hospitalized, and 126 recovered. The discordance of the locations of the human fatalities, predominantly among unrelated individuals in the north and the epicentre of the avian disease in the south, is consistent with the assertion that as yet there has been no significant human-to-human transmission of disease. However, the route of transmission of the avian virus to humans has yet to be established. Curiously, one of the 2 suspected human cases in the south has been reported from a province considered to be free of avian disease at present. No reports indicate that health care workers have been infected. All genes are of avian origin, indicating that the virus had not yet acquired mammalian  genes. On 30 March 2004, after 1 month of no new recorded outbreaks of the virus, Viet Nam declared an end to its bird flu crisis that had killed 17% of its poultry population and claimed 16 human lives since its previous outbreak in December 2003. A total of 43.2 million fowl nationwide either died or were culled, causing direct losses of 1.3 trillion Vietnamese dong (USD 82.8 million) to the local poultry industry.
The second wave : since June 29, 2004, AI was reported on 31 farms, in 22 districts, in the 11 provinces of the Mekong Delta: Dong Thap, Vinh Long, Can Tho, Tien Giang, Bac Lieu, Hau Giang, Ba Ria Vung Tau, Tra Vinh, Ben Tre, Kien Giang, and Long An. The results from samples taken from infected fowl in the south confirmed the presence of the H₅N₁ strain. The suspected AI outbreak in the northern Bac Ninh Province was confirmed as fowl cholera (avian pasteurellosis). Another AI outbreak was reported in southern Can Tho city on 3 Aug 2004. All 600 affected chickens on farms in the city's Phong Dien District were culled. As of 29 Jul 2004, the number of fowl affected by AI in Viet Nam was estimated at 63 000 (45 000 chickens, 13 000 ducks, and 15 000 quail) on 30 small-scale farms. By 3 Aug 2004, Viet Nam recognized that 7 provinces -- which had been dealing with recurrences of AI -- had already met the conditions to declare themselves free of the disease, while still maintaining surveillance measures. However, the flood-stricken provinces of Ha Giang, Cao Bang, Thai Binh, Ha Tay, Hai Duong, Phu Tho, Ninh Binh, Hoa Binh, Lao Cai, and Hai Phong City, where poultry movements are expected to occur, should require heightened vigilance, since the risk of AI re-introduction is high. The most recently reported mortalities in birds involved approximately 3400 quails in the province of Hau Giang on 02 Aug 2004. Some 17 000 chickens and other birds have been culled in Hau Giang province in July. The virus has wiped out 17% of the country's fowl population, totaling 43.2 million poultry across 57 of 64 localities, causing losses of VND 1.3 trillion (USD 83.3 million) between late 2003 and March 2004. It killed a further 21 173 chickens, and 1153 ducks and geese, in 18 poultry farming bases, in 8 southern provinces, during the 2nd outbreak in early July 2004. Vietnam declared earlier in October 2004 that it had brought under control its latest outbreaks of AI, which has killed at least 19 people in the communist nation since late 2003. Diplomats, however, questioned whether the timing of the announcement was linked to the influx of European and Asian leaders for the 8-9 Oct 2004 Asia-Europe Meeting (ASEM) in Hanoi. Between 4 Oct and 16 Oct 2004, the country discovered 2000 sick poultry in Long An province, nearly 1000 in Soc Trang province, 150 in Tien Giang province, and a small number of fowl in Ben Tre province. > 44 million poultry have also died or been culled, with over 60 000 of the deaths coming after the government's controversial 30 Mar 2004 declaration that HPAI had been eradicated. Since the end of June to Nov 18, AI has been confirmed in 14 provinces, and 46 984 birds have died or been culled. The case in chickens in Soc Trang Province on 1 Oct 2004 was confirmed to be AI H₅ (no N type reported to date). The most recent confirmed H₅ infection was reported on 11 Oct 2004 in a chicken farm in Tan My Chanh, My Tho Provincial City, Tien Giang Province with 1200 deaths out of total 3000 chickens. A new case was suspected in mid-November in Can Tho City, Binh Thuy District in 20 chickens raised by a household, the flock has been culled. 20 chickens raised by a household in Binh Thuy district in the southern city of Can Tho were found to have been affected by H5 in mid-November, all of them were already killed, local newspaper Liberation Saigon on Thursday [18 Nov 2004] quoted the country's Department of Animal Health as saying.
Since August 2004, Viet Nam has detected 4 human cases :
• 4 suspected victims all from the southern Mekong Delta province of Hau Giang, around 106 miles (170 km) southwest of Ho Chi Minh City (3 of the 4 suspected victims were from the same family, and included at least one high school student) died between 30 Jul and 2 Aug 2004
• deaths of 5 children aged between 14 months and 4 years, from the beginning of August 2004 to Thu 9 Sep 2004
• at least 8 patients, 3 of whom have died, have been treated in hospital on suspicion of having AI. Samples from the 3 fatal cases have been identified as H₅ serotype virus, and a sample from one of the 3 has been identified as H₅N₁ serotype virus. It is likely, therefore, that these patients have contracted AI A (H₅N₁) virus, but the nature and location of their exposure is still unclear. Person-to-person transmission appears to have been excluded
• a 4-year-old boy died on 2 Aug and an 11-month-old girl died on 4 August in the northern Ha Tay province, 20 kilometers west of Hanoi.
• a 27 month-old baby boy from Long My (the district of Hau Giang province where one person was confirmed to have died of laboratory confirmed H₅N₁ infection on 2 Aug, and where 3 others died of suspected bird flu but were not tested for the disease) was admitted to the hospital, on Sat 14 Aug, after 2 days of displaying a high fever after he had eaten duck raised by his family from an animal that had died mysteriously (AI virus should be inactivated by normal methods of cooking, therefore, transmission of the virus must have occurred prior to cooking)
• a 14-month-old baby boy who was hospitalised in Hanoi on 28 Aug 2004 and then transferred to the Central Paediatric Hospital for specialist care, died on Sun 5 Sep and was confirmed to have died of H₅N₁ infection
• a 25-year-old woman died on 6 August in Hau Giang province
• a 69-year-old man who returned after a 15 day vacation visit to Viet Nam and Cambodia was hospitalised in isolation in the intensive care unit at the Central University Hospital in Nancy, Alsace, northeastern France with symptoms suggestive of AI virus infection on Thu 2 Dec 2004, but blood and tissue samples sent to the Pasteur Institute in Paris tested negative for AI A(H₅N₁) virus
• a 16-year-old girl from the southern Mekong Delta province of Dong Thap, which had slaughtered a chicken she brought with her from Dong Thap province to southern Tay Ninh province, where she was visiting her uncle, developed the disease's typical symptoms of high fever, coughing and breathing difficulties on 19 Dec 2004, was admitted to a clinic in Tay Ninh province on Dec 24, before being transferred to the Hospital for Tropical Diseases in Ho Chi Minh City on 26 Dec, where she died on Sat 8 Jan 2005 after spending 2 weeks breathing with a respirator. Tests confirmed AI A(H₅N₁) virus. None of her uncle's 8 family members developed AI symptoms, and the man's house was disinfected
• a 6-year-old boy from the southern province of Dong Thap died on 30 Dec 2004
• a 9-year-old boy from Cang Long district, of the southern Mekong Delta province of Tra Vinh (one of the 8 provinces which reported the recurrence of bird flu) was admitted at the provincial clinic, then transferred to the Hospital for Tropical Diseases in Ho Chi Minh City on Tue 4 Jan 2005 together with a 14-year-old body, and died the same day. Tests confirmed AI A(H₅N₁) virus. He did not eat chicken but had been infected when he swam in a channel where residents disposed of bird flu infected poultry^ref
• a 18-year-old girl from Tien Giang province (in an area where there are bird flu-infected fowl) developed symptoms on 1 Jan 2005, was hospitalized on Jan 5 and died on Jan 19
• her 15 year old sister is an additional suspected case
• a 18 year-old woman from Hau Giang province in the Mekong Delta, who was a suspected AI case, was admitted to hospital on 1 Jan 2005 and died on Mon 10 Jan 2005
• a 35 year-old woman from Viet Nam's southern province Tra Vinh (in an AI affected area) was admitted to hospital on 9 Jan, transferred to Hospital of Tropical Diseases in Ho Chi Minh City on Tue 11 Jan 2005 with symptoms of high fever and lung infection, 14 days after she killed and ate a diseased chicken (she was hired by a neighbour to bury dead ducks and pluck sick ducks' feathers for sale 4 days before she developed fever), and died on Jan 12
• a 46 -year-old man resident in Thai Binh province, developed symptoms on 26 Dec 2004, was admitted to hospital in Hanoi and subsequently died of pneumonia on 9 Jan : after 2 initial negative tests, a 3rd postmortem test resulted positive for AI.
• his 42-year-old brother (Nguyen Thanh Hung) resident in Hanoi, who had provided bedside care for his brother, developed symptoms on 10 Jan 2005, 9 days after his brother fell ill, and was admitted to the same hospital in Hanoi on 12 Jan with symptoms of high temperature and damaged lungs. After an initial negative test, 2 following tests resulted positive for AI, making it the 1st case of the deadly disease in the capital and the north of the country. Since admission to the institute the patient has felt better and is set to be discharged from the Tropical Disease Institute on Fri 28 Jan. The patient has not had contact with fowl and does not live in an AI hit area.
• his 36-year-old brother from Viet Nam's northern Thai Binh province received medical checkups at the institute in the 3rd week of January 2005, tested positive for AI A (H₅N₁) virus and is receiving treatment at the Tropical Disease Institute in Hanoi
The investigation surrounding the 3 brothers is considering 2 hypotheses :
• the 1st hypothesis includes the possibility that the 42-year-old man may have acquired his infection directly from his brother. All evidence to date suggests that isolated instances of limited, unsustained, human-to-human transmission can be expected from AI viruses. Their occurrence does not call for any change in the present level of pandemic alert. Intensified surveillance for respiratory symptoms in close contacts of the 2 men has been initiated in both Tai Binh Province and Hanoi, and it is reassuring that no cases of respiratory illness have so far been detected among these people. Health authorities in Viet Nam have launched an immediate investigation of the source of infection in the 2 brothers. WHO staff in that country are being kept closely informed. Up to the present there has been only a single instance of possible person-to-person transmission, and that was in Thailand in September 2004
• the 2nd hypothesis is focusing on a possible direct source of poultry-to-human transmission. Preliminary findings point to a family meal in which a dish containing raw duck blood and raw organs (a Vietnamese delicacy) was served at a local market on 29 Dec 2004. Public health officials in Viet Nam have repeatedly advised against the consumption of dishes made with fresh duck blood or with raw or inadequately cooked poultry products. As a precautionary measure, similar culinary practices involving dishes containing raw poultry parts or organs should be avoided in all countries experiencing outbreaks of H₅N₁ HPAI in poultry. To date, most human cases linked to contact with poultry are thought to have acquired their infection following exposure to dead or diseased birds around households. Evidence suggests that particularly risky exposure occurs during the slaughter, defeathering, and preparation of poultry for cooking. Proper cooking destroys the H₅N₁ virus. In general, WHO recommends that poultry should be cooked until all parts reach an internal temperature of 70°C. No cases of H₅N₁ infection have been linked to the consumption of thoroughly cooked poultry and egg products. Media reports that a 3rd 35-year-old brother has been hospitalized have not been confirmed
The timings of the apparent infection of 2 of the 3 brothers favored person-to-person transmission of infection rather than contraction of infection from a common food source.
• a 17-year-old boy from Phuoc Long district in the southern province of Bac Lieu was admitted to hospital on 10 Jan 2005 and died on 14 Jan : samples tested positive for AI on 25 Jan. The boy slaughtered a chicken before showing symptoms
• a 35-year-old woman from the southern Mekong Delta province Dong Thap developed symptoms on 14 Jan, was admitted to the Hospital for Tropical Diseases in Ho Chi Minh City on 20 Jan and died on 21 Jan. She tested positive for the H₅N₁ serotype of AI virus. The woman developed a high fever a week after slaughtering a duck together with ther daughter : the woman did not eat the duck. The woman might also have been infected by stork droppings in her lotus pond where she often worked. She did not slaughter or eat sick or dead chickens, but she often had a bath in a canal which contained dead fowl, her relatives said.
• her 13-year-old daughter from Dong Thap province developed symptoms on 20 Jan 2005, was hospitalized on 22 Jan, tested positive for the H₅N₁ serotype of AI virus and died on Jan 28 at Pediatric Hospital No. 1 in Ho Chi Minh City. In view of the 6-day interval between dates of symptom onset in the mother and her child, limited human-to-human transmission, as seen during similar events in the past, cannot be ruled out at this stage.
• a 10-year-old girl from Long An province developed symptoms on 13 Jan 2005, was hospitalized on 20 Jan, tested positive for the H₅N₁ serotype of AI virus and died at 20:00 on Jan. 30 at Pediatric Hospital No. 1 in Ho Chi Minh City. The girl developed a high fever and bad cough a week after helping her family bury some dead chickens.
• a 66-year-old man from Hanoi city was admitted to hospital on 25 Jan 2005, is now being treated at a Hanoi hospital with confirmed H₅N₁ serotype of AI virus and will be discharged in the Feb 8 week
• a 30-year-old man (Han Ngoc Manh) from Hung Yen province had contact with sick fowl, was hospitalized on 22 Jan 2005 and is now being treated at a Hanoi hospital with confirmed H₅N₁ serotype of AI virus : he was discharged in the Feb 8 week (31 Jan?)
• a 30-year-old man from Phu Tho province had contact with sick fowl, was hospitalized on 23 Jan 2005 and is now being treated at a Hanoi hospital with confirmed H₅N₁ serotype of AI virus (?)
• a 32-year-old man from the province of Phu Tho, 80 km (50 miles) northeast of the capital Hanoi, developed a high fever, coughing, and breathing difficulties on 12 Jan 2005, and died on Thu 27 Jan 2005 after spending 5 days in Bach Mai Hospital in Hanoi. The man's family raised poultry but none of them has shown signs of illness : there were no avian influenza outbreaks reported among poultry in his village. However the man was involved in the trade of poultry from infected areas 6 months ago but had stopped since then
• a 39-year-old man from central Quang Nam province died on Jan 30 in a hospital in central Da Nang city. If confirmed, he would the 1st casualty of the virus in central Viet Nam.
• a 24-year-old man from Hanoi was admitted to the city's Bach Mai hospital Jan. 25 with a high fever and cough before testing positivefor the H₅N₁ strain of the virus. The man had been removed from a respirator and was recovering
• a 4-year-old boy in southern Vietnam presented with severe diarrhea, followed by seizures, coma, and death. The CSF contained 1 WBC/mm³, normal glucose levels, and increased levels of protein (8.1 g/dl). The diagnosis of avian influenza A (H₅N₁) was confirmed by isolation of the virus from cerebrospinal fluid, fecal, throat, and serum specimens
• the patient's 9-year-old sister had died from a similar syndrome 2 weeks earlier
In both siblings, the clinical diagnosis was acute encephalitis. Neither patient had respiratory symptoms at presentation. These cases suggest that the spectrum of influenza H₅N₁ is wider than previously thought^ref. Continuing doubts about the sensitivity of the diagnostic test performed in different laboratories makes many of these statements difficult to interpret, and much is being concluded from a few cases. For example, it has been widely reported that encephalitis may be associated with avian influenza A (H₅N₁) virus infection, whereas 100 encephalitis cases examined subsequently were found to be H₅N₁ virus-negative. Convincing seroprevalence data are still lacking
• up to 10 additional suspected human cases are under investigation another patient died on Thu 13 Jan 2005 in Mekong Delta province :
• a 48-year-old man, his younger brother (suspected case of transmission of infection from person to person ?) and a 62-year-old man were hospitalized on Sat 15 Jan 2005 with acute pneumonia, which doctors in Hanoi suspected could be caused by AI virus, the Quan Doi Nhan Dan daily reported on Mon 17 Jan 2005. The 48-year-old man died, and the other 2 patients were in critical condition. If the cause of the man's death is confirmed as bird flu, it would be the 1st fatality in the north of the country, but a physician from Hanoi's Clinical Institute for Tropical Disease denied that the 48-year-old man had AI
• a 14-year-old boy, was taken to a Ho Chi Minh hospital with high fever and coughing on Sun 16 Jan 2005 from the southern province of Tra Vinh
• a 10-year-old child from northern Ha Tay province admitted on 20 Jan the Hanoi-based National Hospital of Pediatrics is suspected to have contracted H₅N₁
• 2 local people, a 15-year-old teenager from southern Kien Giang province and a 24-year-old woman from central Binh Dinh province, have just been admitted to provincial hospitals after showing symptoms of high

temperature, cough, and damaged lungs. The patients are suspected to have contracted H₅N₁, since they either ate chicken or traded poultry.
• 6 other children suspected of avian infections are being treated at Nhi Dong 1 (Children 1) hospital in the city
On Jan. 29-30, 7 people from Vietnam's northern region were admitted to the Tropical Disease Institute in Hanoi capital with symptoms of bird flu infections : the tests have proved negative so far. 8 people from Viet Nam's northern region have been hospitalised with AI symptoms on Thu 3 Feb 2005, raising the total number of confirmed and suspected cases under treatment there to 21. Of the patients, 3 have been confirmed to have contracted AI A (H₅N₁) virus infection.
• 5 cases from Thai Binh province, 110 km (70 miles) southeast of Hanoi and far from the southern Mekong Delta where the outbreaks began in December.
• a 21-year-old man (Nguyen Sy Tuan) from Thai Thuy district developed symptoms on 14 Feb 2005, was admitted to the hospital on 20 Feb, was transferred to the Tropical Disease Institute in Hanoi on 22 Feb after exhibiting a high temperature and tested positive on Feb 25. Tuan left his home among the glistening paddies of northern Vietnam's rice-growing region more than a year ago for Haiphong, on the coast, where he worked harvesting seaweed for use in local cuisine. In early February, he returned to his family's simple brick house to celebrate the Tet New Year holiday. Tuan slaughtered a chicken (goose ?) for a Lunar New Year meal early in Feb, cutting its neck while his 14-year-old sister clutched the wings and legs. The bird was likely infected, and soon the siblings were, too. He ate raw goose blood before exhibiting bird flu symptoms. After 10 days, with his breathing failing, the doctors intubated and put him on a ventilator. The infection spread to his kidneys and liver. On Apr 2005 the young man has begun to eat rice again and can finally breathe without a mechanical ventilator : he left the hospital on May 13
• his 14-year-old sister (Nguyen Thi Ngoan) developed symptoms on 21 Feb 2005 and was hospitalized at Hanoi the following day, where she laid in the cot beside her brother and her temperature soared to 105°F. She was under treatment at the Thai Binh Hospital. After initial negative tests, she tested positive on Feb 27. But the fever broke after 4 days and returned to normal within 2 weeks : Ngoan went back to school in late March as a local celebrity, teased by her peers as "Miss H5." As for her brother, she had eaten chicken at a friend's house during Lunar New Year festivities earlier in Feb, too. The family did not raise any poultry, but there were bird flu outbreaks in their neighbourhood.
• their 80 (81 ?)-year-old grandfather despite asymptomatic tested positive on Mar 9 with the H₅N₁ avian influenza virus. The man remains in good health at his home without any of the disease's typical symptoms of high fever and breathing difficulties. None of the remaining 12 family members have tested positive for the virus. The grandfather has been given anti-viral drugs and asked to limit his contact with other people. The man's family had raised chickens, one of which died during Tet. The man then gave the 3 remaining chickens to his daughter, the mother of the 21-year-old man and his 14-year-old sister. He drank raw duck blood during the Tet
• a 26-year-old male nurse (Nguyen Duc Tinh) from Thai Thuy district's Healthcare Center in Thai Binh province who tended the 21-year-old man from Thai Binh with bird flu was admitted to the institute on Feb. 28 with symptoms of high temperature, coughing and breathing difficulty, and tested positive on Mar 7. No members in his family have showed symptoms of bird flu. But just 2 weeks after joining Tuan in the Hanoi hospital, Tinh was discharged and went back to his village.
• a second 41-years old female nurse who cared for the 21-year-old man was admitted to Hanoi's Bach Mai Hospital on Thu 10 Mar 2005 with a high fever, coughing and a lung infection and remains in critical condition : she tested negative on Mar 14. Health authorities are closely monitoring the health of 2 doctors and 2 other nurses at the center who had contact with the 21-year-old man. None of them have shown any symptoms
• a 36-year-old man (Nguyen Thanh Chung) from Vu Van Commune in the Vu Thu district contracted bird flu after coming into contact with infected poultry, was admitted to the Tropical Disease Institute in Hanoi on Feb 22, tested positive on Feb 26, but negative on the 2nd examination.
• a 69-year-old man was taken to a hospital in the northern province of Thai Binh developed symptoms on 19 Feb, was admitted to the hospital the same day, and died on 23 Feb 2005. He tested positive on Feb 27. The man had eaten chicken with his family during the Lunar New Year
• her 68 (61?) -year-old widow tested positive on Wed 9 Mar 2005 despite being completely healthy. She took care of her husband when he was sick. Other than that, she said she ate only pork, and all 4 chickens raised in her house tested negative for avian influenza. She had slaughtered a chicken for a meal on the 3rd day of the Lunar New Year Festival (early February 2005). The woman, in good health in her home town, received treatment with oseltamivir
• a veterinarian woman was admitted to the Institute of Tropical Diseases in Hanoi city on Wed 9 Mar 2005. She has frequently had contact with poultry, including infected fowl.
• a man died on Mar 13 in the southern province of Kien Giang, 3 days after he was transferred from the Chau Thanh district health center, where he had been on a respirator,
• a 35-year-old woman from a Hanoi district who works as a rubbish collector in the city and has frequently been present in live poultry markets, developed symptoms on 18 Feb 2005, was hospitalized on 24 Feb 2005, and tests confirmed on Mon 28 Feb 2005 that she had contracted avian influenza virus
• from Chau Hoa commune of the central Quang Binh province : 195 patients showing symptoms (?)
• Tuyen Hoa district :
• in late February 2005, a family, who live in an area hit by bird flu in early February, slaughtered a chicken given by one of their relatives for meal, and several days later, the family's 3 children suffered a sudden illness (the sister came down with a fever only 2 days later)
• a 13-years older female baby was hospitalized with a high fever died in Quang Binh hospital from AI infection on 9 Mar 2005 : she was immediately buried by her family and diagnostic samples were not taken
• her 5-years old brother was admitted to hospital on 12 Mar and transferred to Hue Central Hospital on Tue 15 Mar 2005 with typical bird flu symptoms: high fever, coughing, and respiratory problems. He tested positive on Mar 17 is being treated in an isolation ward with respiratory support equipment, but is recovering
• her aunt who cared for her is being closely monitored in her residential area since she has a light fever and breathing difficulty
• apparently a younger sister was left unscathed
• a 41-year-old man was admitted to a hospital in Hue central city on Mon 21 Mar 2005, after having a high fever for a week
• a 16-month-old boy was hospitalized in Hue central city on Tue 22 Mar 2005 on suspicion of having contracted avian influenza A. His parents said he had fever. But he does not have any fever anymore, and we don't see any symptoms of avian influenza
It is not yet clear whether these people, some of whom had reportedly eaten sick chickens, have the symptoms of the deadly bird flu or normal influenza. Of the 195 patients showing symptoms, 108 are from Kinh Chau village, while the rest live in other villages in Chau Hoa commune. The outbreak hit the province's Kinh Chau village in Chau Hoa commune just ahead of the Lunar New Year holidays, which started on 9 Feb 2005. The province is currently trying to stop the spread of the influenza by culling all poultry in the commune.
• Quang Trach district : on 17 Mar 2005, a person was admitted to a hospital in the district with the bird flu symptoms of fever and breathing difficulty.
The (200-people) figure seems to be very exaggerated : a team from the provincial health department sent to the commune on Sat 19 Mar 2005 discovered very few sick people so far after examining 7 families. When local health officials made an inspection, they found that 300 out of 500 chickens raised in the locality had died. In another development, the Market Watch Team of northern border Lang Son Province seized > 1.6 tons of chickens illegally imported through local border gates. All seized chickens, which were not quarantined, have been culled. The 1st avian influenza tests carried out on both sick patients and residents without symptoms were all negative on Mar 24
• a ? from Hai Duong province and the other from Nam Dinh province, were admitted to the Tropical Disease Institute in Hanoi on Tue 1 Mar 2005
• from northern Quang Ninh province, which borders China :
• a 40-year-old woman developed symptoms on March 13 and was transferred in stable condition to Hanoi's Bach Mai Hospital on March 17. She and her family ate chicken on March 10 and she began developing the disease's typical symptoms of fever, coughing and laboured breathing 4 days later and tested positive on Mar 25
• a 34-year-old doctor who worked at the Viet Nam-Sweden hospital in Uong Bi fell sick at work on Fri 1 Apr 2005, his breathing worsened quickly despite emergency treatment for SARS, and died on Sun 3 Apr 2005
• a 21-year-old woman, used to work at a hairdressers's shop, hospitalized in early March with fever and coughing tested positive for both avian influenza A (H₅N₁) virus and HIV-1 on Apr 14 2005. Quang Ninh province bordering China has one of the highest number of HIV carriers in Viet Nam, most of them drug addicts and prostitutes. The fate of the patient experiencing HIV and AI virus co-infection may give an initial indication of any effect of HIV status on susceptibility to avian influenza virus infection. The HIV patient -- though weak -- appears to be resisting AI virus infection better than some of those not known to be HIV carriers, and hopefully the outcome will show that an HIV/AIDS status does not predispose individuals to greatly enhanced risk
• a 17-year-old girl from Nam Dinh province (90 km (56 miles) south of Hanoi), was hospitalised in stable condition at Hanoi's Bach Mai Hospital on ? Mar, died on 23 Mar and tested positive on Mar 25. There had been no outbreaks among poultry in her village
• from the northern port city of Hai Phong :
• 5 members of one family from Kien Thuy rural district were admitted to the city-based Viet- Tiep Hospital on March 22 2005 with coughing and breathing difficulties : they all tested positive on Mar 28 and are now in stable health condition.
• a 39 (35?)-year-old man (Vu Van Son)
• his 33-years-old wife
• 3 daughters aged 4 months old, 3 (13?) years old and 10 years old
Before exhibiting bird flu symptoms, they ate sick chicken raised by themselves. The family, who live in a bird flu-hit area, have their flock of nearly 200 chickens recently culled by local veterinarians. Earlier, over 200 chickens of the flock died. Several days after admitting the 5 patients, the hospital received 2 suspected cases of bird flu infections:
• a 41-year-old woman neighbor of the family was hospitalized on suspicion of having contracted avian influenza A (H₅N₁) on 25 Mar 2005 after suffering cough and breathing difficulty
• a child
All the 7 patients live in the same commune.
• a 12-year-old girl, who lives near a poultry slaughterhouse, was in an isolation ward on Mon 4 Apr 2005 in the northern city of Haiphong
• a 30-year-old patient (Cao Lu Uy) from the neighboring province of Quang Tri was hospitalized on 23 Mar 2005 at the Hue Central Hospital in central Hue city. The patient has not had contact with sick poultry. 20% of total waterfowl flocks in Vietnam's central Quang Tri province was been found to contract bird flu virus strain H₅N₁ on 24 Jun 2005. The provincial Veterinarian Bureau culled over 23 000 waterfowl, mainly ducks, in the 38 infected flocks. It will further the culling if the 144 untested flocks prove to be infected with H₅N₁.
• a 25-year-old woman was taken to Ho Chi Minh City's Hospital for Tropical Diseases on Tue 29 Mar 2005 with coughing and fever after returning from Cambodia
• a 27-year-old Vietnamese woman who drank duck blood tested positive for the H₅N₁ poultry virus after being admitted to the hospital with high fever on Fri 1 Apr 2005 in the central province of Ha Tinh
• a woman was taken to hospital in Hue on Sun 3 Apr 2005
• a 10-year-old girl died on 27 Mar 2005 in St. Paul's Hospital in Hanoi and tested positive on Mon 4 Apr 2005
• 2 other patients have been diagnosed with the H₅N₁ virus in the northern provinces of Ha Tay and Hung Yen between 2 and 8 Apr 2005, but no deaths were reported
• a 20-year-old Cambodian woman from Kampot province (the home of 4 other people who died of H₅N₁ in 2005) developed symptoms since beginning of May, was treated at a private clinic in Cambodia before being transferred on Wed May 11 2005 to the General Hospital in Vietnam Kien Giang province, which borders Cambodia, with a suspected H₅N₁ infection. She is in stable condition. Her high fever and coughing have almost disappeared, but 2 x-rays of her lungs showed serious damage. Dead chickens were reported in her neighborhood a month ago. The woman's samples have been sent to the Pasteur Institute in Ho Chi Minh City for testing. Preliminary tests on May 16 showed she was not infected by the virus, but

more tests were being conducted.
• a 55-year-old man (Cao The Hai) from Vinh Phuc province, tested positive on May 13 at the Institute of Tropical Diseases in Hanoi. The new case comes after a 3-week period without any reported human or poultry cases. Such lulls have sometimes prompted authorities to declare victory over avian flu.
• a 52-year-old man from the northern province of Vinh Phuc was hospitalized with a fever last Thu 12 May 2005 after eating the chicken with his family, tested positive on May 16 (the country's 1st human case in a month) and remained in stable condition on Tuesday at Bach Mai Hospital in Hanoi
• a 58-year-old man from northern Thanh Hoa province, some 160 km south of Hanoi had AI-like symptoms of high fever, coughing and breathing difficulties on 20 Apr 2005, were admitted to Bach Mai Hospital in Hanoi and tested positive for the virus on Sun 15 May 2005. There were dead chickens reported in the man's neighbourhood a month ago and his family also slaughtered chickens for meals
• 3 additional human cases of infection with H₅N₁ avian influenza virus were confirmed in Hanoi during the last 2 weeks of May 2005. All the 3 have been infected in relation to sick poultry
• a 30-year-old man discharged from Hospital
• 2 women from the northern provinces Thanh Hoa and Vinh Phuc are still being treated in a Hanoi hospital
The most recently detected case was reported on 26 Apr 2005. In the same communication, an additional death from the disease that was earlier reported as a suspected case was confirmed. Last month, health officials said a 46-year-old man from the northern province of Hung Yen, 65 km (40 miles) southeast of Hanoi, was suspected of having died of the H₅N₁ virus.
• 6 people from Vietnam's northern region have just been found to have contracted bird flu virus strain H₅N₁ and admitted to Tropical Diseases in Hanoi capital city, which is now treating 8 bird flu patients in all : 7 are showing good signs of recovery, and 1 is in critical health condition.
• between 1 to 17 Jun 2005, 4 cases of human infection with H₅N₁avian influenza virus were reported
• 2 of the patients are from Hanoi
• a 73-year-old Vietnamese Hanoi resident, one of 4 people infected by the H₅N₁ virus being treated in hospital, died on Tue 28 Jun 2005 after being admitted on Thu 23 Jun 2005
• 1 is from the nearby province of Hai Duong
• 1 is from the central province of Nghe An
All 4 of the patients are alive. At present, a total of 7 patients are being treated for H₅N₁ avian influenza at a hospital in Hanoi.
• a male  doctor at the institute, who has taken specimens from bird flu patients for testing, was found infected on Fri 17 Jun 2005, but a

2nd test turned up negative.
11 avian influenza patients have been hospitalized at the National Institute for Clinical Research of Tropical Medicine in Hanoi. The center is also treating 12 suspected avian influenza cases. Their conditions are all "relatively stable".
2 patients and 3 suspected cases were admitted to the Institute of Tropical Diseases in Hanoi capital city from June 18-19. Currently, the institute is treating 28 people with bird flu symptoms, of whom 13 have been tested positive to H₅N₁.
• one positive case in the northern province of Ha Tay in May 2005
• bird flu has killed another Vietnamese on Jul 14, taking the country's toll to 40, and infected 3 more of 18 patients in the isolation ward of Hanoi's National Institute for Clinical Research of Tropical Medicine. 13 others were suspected of being infected with the virus, while 2 had the human influenza.
• a 72-year-old man from Hanoi died June 28
• a 24-year-old man named Le Hoang Anh from southern Tra Vinh province died Mon 25 Jul 2005 and tested positive on Thu 28
• a 26-year-old woman named Doan Thai Truc in southern Ho Chi Minh City died Wed 27 Jul 2005 and tested positive on Thu 28
• a 49-year-old woman named Nguyen Thi Them from the Quoc Oai district in northern Ha Tay province developed symptoms on Jul 15, received treatment at a provincial hospital for 3 days starting on 27 Jul 2005. The woman had bought a chicken at a local market and cooked it. She tested positive on Aug 2 and remains hospitalized.
• a 35-year-old man from Ben Tre Province in the Mekong Delta developed symptoms on 25 July 2005 and died on July 31, a day after he was taken to hospital with a high fever. The man slaughtered and ate 2 chicken that had the H₅N₁ virus. He retrospectively tested positive in September^ref
• a 30-year-old man from Tan Xuan Commune, southern Ben Tre Province, ate sick fighting cocks after slaughtering them, was admitted to Nguyen Dinh Chieu Hospital with acute pneumonia at the end of July 2005, died the day after, and tested positive for the H₅N₁ virus. His is the 1st death from avian influenza virus infection in Ben Tre province.
• a ?-old male/female ? from Soc Son, a district on the outskirts of Hanoi, died from acute pneumonia on Sun Aug 28, and tested positive for H₅, but the government had not spotted any outbreaks in poultry in August
• a 14-year-old girl and a 26-year-old man from Quang Binh province ate duck and a chicken's egg around a week before they became ill. The girl was admitted to hospital on 21 Oct 2005 and died on 23 Oct 2005, and the man died 26 Oct 2005 within an hour of arriving at the hospital. Their bodies had been sent home to be buried. the victims were not related and from different towns in the province, which is around 500 km (310 miles) south of the capital Hanoi. These are the first human cases of avian influenza to be reported from Viet Nam since the end of August 2005. It seems that the deaths of these 2 unrelated patients have been attributed to avian H₅N₁ influenza virus infection on the basis of clinical assessment alone, and that no laboratory testing has been undertaken, nor is likely to be undertaken since the bodies of the patients have been returned to their families. Therefore the status of these cases remains "suspected" and may remain so. On Nov 3 the Saigon Giai Phong (Liberation) newspaper quoted Deputy Health Minister Trinh Quan Huan as they were negative for bird flu
• a 27-year-old man with symptoms of the disease had been sent to a better-equipped hospital in Hue City, central Viet Nam, for treatment
• a 25-year-old woman in Hanoi woman was rushed to hospital on Tue 1 Nov 2005 with respiratory difficulties and a slight fever, symptoms; her mother said she bought a slaughtered chicken for a family meal of 4 people but that only her daughter became sick.
• a 24-year-old pregnant woman from Bac Giang province (where bird flu has infected poultry in 3 communes, killing > 3000 chickens, ducks and geese) was admitted to hospital with a fever and respiratory problems; she tested negative for H₅N₁
• a 35-year-old man from Hanoi developed a slight fever after eating with his family a prepared chicken bought from a market near his house in the Dong Da District of Hanoi on Oct 22, was taken to Bach Mai hospital on October 26 with respiratory difficulties, died on October 29, and on Nov 8 was confirmed as the first human victim of the latest outbreak. Other family members did not show any symptoms of bird flu
• a 68-year-old man in the central province of Quang Tri was admitted to the General Hospital in Hue city on Nov 5 with a critical lung infection and fever and died on Sun Nov 6, but there is no confirmation of bird flu infection yet
• a 43-year-old man from the northern city Hai Phong ate poultry during his stay in the southern city of Vung Tau, was admitted to a hospital on 1 Nov 2005 after returning home, died on 2 Nov 2005 from respiratory failure and tested positive for H₃N₀. The diagnosis of H₃N₀ is clearly erroneous:

possibilities are that the patient has contracted H₃N₂ human influenza virus infection or even H₃N₈ avian virus infection (a combination of H and N antigens found previously in ducks). Alternatively the N₀ designation may mean no more than that the subtype has not been identified.
• a student was being tested in hospital after eating chicken eggs on Fri 11 Nov 2005
• a 78 year old woman died from serious pneumonia in the central province of Quang Binh on Fri 11 Nov 2005.
• a man suspected of being infected with the H₅N₁ strain fled a hospital quarantine unit on Nov 25, 2005. Officials in his home province have been trying to persuade him to return to the hospital
• a 15-year-old boy from Hai Phong Province developed symptoms on 14 Nov 2005, was hospitalized on 16 Nov 2005, tested positive on 25 Nov was discharged from hospital and is recovering.
• a 3-years old toddler from the southern province of Hau Giang died on Mon 12 Dec 2005, 7 hours after admission to hospital for severe lung infection with symptoms pointing to bird flu infection but repeated tests showed he did not have that virus. The child's illness was ascribed similarly to the

onset of colder weather and the prevalence of human influenza virus infections.
• a 36-year-old male teacher from the southern province of Soc Trang died on Dec 2?, 2005, but tests showed he not have H₅N₁ virus. Chicken is traditionally offered to ancestors at Tet, which falls in late January in 2005^ref

(total : 92 cases in 28 cities and provinces since 26 Dec 2003 (66 from 21 cities and provinces since 16 Dec 2004 [40 according to WHO]) according to Vietnamese authorities; 42 deaths since Dec 2003 [40 according to WHO] (23 since 30 Dec 2004 [22 according to WHO]))^ref. Viet Nam has so far experienced 3 outbreaks of bird flu in humans, killing 32 local people. In the 1st outbreak, lasting from 26 Dec 2003 to 10 Mar 2004, a total of 23 people were infected with H₅N₁ virus, of whom 16 died. In the 2nd outbreak from 19 Jul 2004 to 26 Aug 2004, 4 people contracted the virus, and all of them died. In the most recent outbreak starting 16 Dec 2004, Viet Nam has identified 41 local cases of avian influenza H₅N₁ virus infection, of whom 16 have died, 5 have fully recovered, and one remains hospitalized. The drop in the bird flu mortality rate was more marked in northern Vietnam than in the south. While the virus in southern Vietnam is still killing at the same pace as last year, the rate in the area around Hanoi and elsewhere in the north has dropped from that level to as low as 20%. Vietnamese health experts said their suspicion that the disease is shifting is further supported by preliminary research showing a genetic change in the virus in the north resulting in the production of a protein with one less amino acid than in the south. The mortality rate for bird flu in Vietnam in 2005 is about 35%, almost exactly half that of 2004.
As of Mon 28 Feb 2005 the number of unofficial cases (i.e., the aggregated WHO, press and governmental figures) in East Asia from Jan 2004 to the present is 65 with 46 deaths; whereas the official (WHO) figures are 55 cases and 42 deaths. During the period 28 Jan 2004 to 25 Oct 2004, the unofficial and the official figures are the same: i.e. Thailand 17 cases and 12 deaths; Viet Nam 27 cases and 20 deaths; giving totals for East Asia of 44 cases and 32 deaths. The numbers of cases reported from mid-Dec 2004 to 28 Feb 2005 are:
• country / unofficial (official) cases / unofficial (official) deaths
• Cambodia / 1 (1) / 1 (1)
• Thailand / 0 (0) / 0 (0)
• Viet Nam / 20 (10) / 13 (9)
• total / 21 (11) / 14 (10)
Vietnamese and international Media reports would suggest WHO's case count is falling seriously behind what is happening on the ground. In the past week alone, four human cases have been reported. WHO's most recent case count -- dated 2 Feb 2005 -- sets the number of human cases of H₅N₁ infection since January 2004 at 55, with 42 deaths. But tallies kept by the Center for Infectious Disease Research and Policy at the University of Minnesota tell another story.
Since 31 Jan 2005, WHO has received > 90 clinical specimens sampled between 24 Dec 2004 and 29 Jan 2005 from confirmed and suspected H₅N₁ human cases in Viet Nam. Antigenic and genetic analyses are being conducted in the WHO Collaborating Center for Reference and Research on Influenza and the WHO H₅ Reference Laboratory in the National Institute of Infectious Diseases, Japan. So far, 9 viruses have been isolated from specimens collected from southern Viet Nam. Results show that:
• these viruses belong to group Z and are genetically highly similar to the viruses isolated in 2004, including A/Vietnam/1194/2004 and A/Vietnam/1203/2004, which are the prototype vaccine strains recommended by WHO for pandemic influenza vaccine production.
• except for one virus, all the rest are antigenically closely related to A/Vietnam/1194/2004 and A/Vietnam/1203/2004.
• at the receptor recognition site, there appears to be an avian receptor preference.
The conclusions so far:
• very little mutation has been observed since 2004.
• there is no need to change the prototype pandemic vaccine strain selected by WHO in 2004
• genetically, the viruses continue to show resistance to amantadine.
The continued prevalence of human cases of avian influenza in Viet Nam, and not elsewhere in East Asia, might indicate that there are social and/or genetic factors peculiar to the Vietnamese population that remain to evaluated.
Global Public Health Intelligence Network (GPHIN) : an Internet trolling program developed and maintained by Health Canada.
Viet Nam may have 2 problems with its data on human cases: transparency in reporting and accuracy in testing. The country has lapsed in its reporting of cases to the WHO. > 1 month passed without official reporting of cases, despite widespread media reports of several new cases. Ongoing monitoring by Center for Infectious Disease Research & Policy (CIDRAP) News, Academic Health Center, University of Minnesota also shows substantial discrepancies between official and unofficial numbers^ref. Because the WHO relies on official reports for its case counts and as the basis for advice to member countries, the lack of reporting has an impact. WHO officials had requested reports in person and in writing. The pattern of cases in Viet Nam has not changed recently. The press reports suggest that the missing cases are sporadic^ref
• reanalysis of samples from Vietnamese patients with flu-like symptoms has revealed on the 3rd week of Feb 2005 that some people originally declared free of avian influenza actually did carry the avian influenza A (H₅N₁) virus. Reassuringly, preliminary genetic analyses at the National Institute of Infectious Diseases (NIID) in Tokyo show that the virus has not mutated greatly since 2004. The death rate for infected patients has so far been very high; 10 of the 11 cases identified in Viet Nam since December 2004 have died, but if many more cases are going unidentified, the mortality rate could be much lower. Samples from the 11 recent cases of avian influenza in Viet Nam, plus those from some 90 suspected cases that tested negative for H₅N₁ virus, were recently sent to the NIID for study. About 1/3 of the samples have been examined so far, and, of these, 7 of the negative results have tested positive. All 7 are said to have recovered from the disease. Fresh tests at Pasteur Institute in Viet Nam on the 3rd week of Feb 2005 confirmed 4 of these positive results. Part of the discrepancy between labs could be accounted for by problems with the original tests. Some reagents were not mixed well, and the results weren't clear. But for 3 cases, the Pasteur researchers -- together with NIID researchers observing -- reconfirmed their earlier negative diagnosis. This is worrying, as it suggests that the Vietnamese test is not sensitive enough to detect all cases. The institute now plans to switch to the more sensitive test used in Tokyo and will ensure better training for its technicians. If many infections have been missed, suspected cases of human-to-human transmission should be investigated again. There has so far been only one documented case of probable human-to-human transmission, but there are strong suspicions that clusters of disease within Asian families may have been transmitted through people rather than birds. The Japanese data now favor an interpretation that avian influenza virus infection of humans is widespread and mostly unapparent. If confirmed, such data should be a cause for rejoicing rather than a reason for generating further alarm and despondency^ref.
• researchers tested hundreds of stored blood samples using Western blotting to see if these showed evidence of antibodies to H₅N₁ virus. Rumors on 25 Jun 2005 are that scores of samples came back positive. As a consequence the Vietnamese authorities have asked for international assistance. The official explanation for this diffidence is the possibility the western blotting is not sufficiently specific to rule out the possibility that it is detecting antibodies to other influenza serotypes than H₅N₁, although for other viruses "westerns" are used as confirmatory tests because they are more specific than the conventional ELISA tests. Westerns are antibodies against antibody tests and are not especially easy to do, but are easier and less hazardous than the current gold standard, the neutralization test which uses live H₅N₁ virus and tissue culture cells.
The Institute of Hygiene and Epidemiology will soon start testing a vaccine on monkeys, chickens and mice with the hope of using it on humans and poultry, as the vaccine has been under research since April 2004.
Between 1-10 Jan 2004 22 new outbreaks had been reported in 7 provinces in the Central Highlands and southern regions at a limited number of farms^ref :
• ... / species / susceptible / cases / deaths / destroyed / slaughtered
• An Giang (hundreds of chickens and ducks have suddenly died since mid-December)
• Bac Lieu / avi / ... / 160 / 110 / 50 / ...
• Ben Tre
• Binh Phuoc / avi / ... / 125 / 30 / 95 / ...
• Can Tho city / avi / ... / 3665 / 205 / 3460 / ... (> 200 chickens raised by Tao Van Loi in Binh Thuy district died on 12 Dec 2004. The local veterinary force culled his 3685 chickens and 4541 eggs worth some 200 Vietnamese dong (12,700 USD) after finding that samples from the dead fowl tested positive for H₅. In mid-December, the force also killed 24 chickens raised by 2 other farmers in the same district, since samples were tested positive to the virus strain. Can Tho's veterinary force sprays antiseptics and bans the transport of poultry in the areas within a radius of 1 km. In Can Tho city, tests on poultry samples taken from the Co Do poultry farm in Vinh Thanh district, Phu Thu ward in Cai Rang precinct, Dinh Mon commune in Co Do district and Trung Kien commune in Thot Not district showed that ducks in these localities have contracted the H₅ virus. The H₅ virus was also detected in serum samples of 460 other ducks in Tan Tao A ward, Tan Binh precinct, on 5 Jan 2005. > 25,700 poultry have been culled as a precaution. The MARD is instructing provinces to keep close watch on poultry flocks and immediately cull infected chickens. Veterinarians have culled up to 11,000 chickens, ducks, quail, and geese to try to contain the virus.
• Hau Giang / avi / ... / 800 / 500 / 300 / ... (some 200 out of 540 chickens in Hau Giang's Long My rural district died last week. Other healthy fowl in the flock have already been culled)
• Long An / avi / ... / 4900 / 3700 / 1200 / ...
• Tra Vinh / avi / ... / 1100 / 300 / 800 / ...
• total / avi / ... / 10 750 / 4845 / 5905 / ...
• Nam Dinh province, Truc Ninh district  / avi / ... / 250 / 917
• Dong Thap
• Tien Giang
• Lam Dong (Central Highlands)
The busy transport and big sales of poultry during the Lunar New Year Festival (in early February 2005) plus complex weather may result in outbreaks in the northern region. Denmark on Dec 20 offered 12 southern localities equipment for bird flu prevention worth some 150,000 US dollars. The equipment includes sprayers, slaughtering tools and protective clothes. Vietnam remains highly alert to potential new outbreaks of bird flu this winter, because cold weather favors the spread of the disease. Free raising of poultry, especially ducks in fields, and rampant transport and sale of fowl before the Lunar New Year, which falls in early February, are also contributing factors to the high risk for the return of bird flu. The country is intensifying anti-bird flu activities such as frequently disinfecting farms, monitoring the transport and import of fowl and their eggs via border gates, and raising public awareness of the disease nationwide, especially in the southern Mekong Delta. It plans to vaccinate poultry if large-scale resurgence of bird flu is reported. According to the Department of Animal Health, since December 2004 to Jan 7, a relapse of bird flu has been seen in 25 communes in 11 localities, namely the southern city of Can Tho, the northern province of Nam Dinh and the 9 southern provinces of Dong Thap, Tien Giang, Long An, Bac Lieu, Ca Mau, Hau Giang, Tra Vinh, Binh Phuoc and An Giang, killing and leading to the forced culling of some 28 700 fowl, mainly ducks and chickens. 54 bird flu outbreaks were found in 51 communes belonging to 29 districts of 9 provinces between 1 and 10 Jan 2005. The Central Highlands province of Lam Dong, the southern provinces of Binh Phuoc, Ben Tre, Tien Giang, Long An, Dong Thap, Bac Lieu and Ca Mau, and the Mekong Delta city of Can Tho have culled > 103,000 infected poultry. The disease seems to spread rapidly; just 3 days before, the Vietnamese authorities mentioned outbreaks in 20 communes and 15 districts of 7 cities and provinces. The 2 added (southern) provinces are Bac Lieu and Ca Mau^ref. By 13 Jan 2005, the country experienced as many as 84 outbreaks in 16 cities and provinces, including Hau Giang, Bac Lieu, Tra Vinh, Long An, Dong Thap, An Giang, Binh Phuoc, Can Tho, Tien Giang, Kien Giang, Ca Mau, Nam Dinh, Lam Dong, Ben Tre, Ha Nam (the first northern province : a flock of 100 ducks in Ly Nhan district) and Hanoi (in a flock of 400 ducks, a flock of 600 chickens in Long Bien urban district), which have killed and led to the forced killing of nearly 168,000 fowl. According to the Veterinary Department, by Jan 17, the epidemic spread to 136 communes of 62 districts in 18 cities and provinces, including Lam Dong, Binh Phuoc, Ben Tre, Tien Giang, Long An, Dong Thap, Can Tho, Bac Lieu, Hau Giang, Tra Vinh, An Giang, Ca Mau, Ha Nam, Hanoi, Tay Ninh, Dong Nai, Ninh Thuan and Quang Nam^ref. A total of 75,454 chickens, 73,703 geese, and 104,850 quail have been culled between 1-16 Jan 2005. Fearing that severe outbreaks of bird flu will happen during the Lunar New Year Festival (early February 2005), when cold weather favors the development of viruses and a larger number of fowl are transported and traded, local veterinary forces are increasing surveillance of areas formerly hit by bird flu, covering poultry farms, markets and slaughterhouses. They attach great importance to monitoring transport and trade. The country's veterinary forces nationwide in the 1st week of January 2005 resumed a 24-hour operation to monitor transport and trade, an operation that was initially applied in early 2004, when bird flu was at a peak in the country. Veterinary cadres are to go deeply into wards and hamlets to monitor poultry flocks so that Viet Nam's Department of Animal Health can have an updated report on new outbreaks and the number of dead and culled fowl each day. Many cities and provinces nationwide have just established hotlines in a move to get the latest news out on the bird flu situation. The southern city of Can Tho -- where nearly half of the samples from ducks raised in the locality tested positive for the bird flu virus strain H₅ -- has publicized 3 such phone numbers. Under the department's recent directive, large volume transport of poultry must get approval from local veterinary agencies, and more quarantine checkpoints must be set up along roads leading to centers of cities and provinces. The capital city of Hanoi has just established 4 checkpoints, raising the total to 12. Some localities, such as Ho Chi Minh City, imposed even stricter rules on the transportation of poultry. Fowl and their eggs that are not quarantined by the agencies or are carried to the city by a simple means of transport, such as bicycles and motorbikes, will be confiscated and then destroyed. Additionally, the city assigns veterinary cadres to be present at all of its 59 slaughterhouses. The cadres are to inspect fowl before they are slaughtered and then packed into plastic bags. To encourage residents to actively detect new outbreaks and prevent poultry raisers from selling their sick chickens, some provinces have offered cash rewards to informers and raised the level of financial assistance to farmers. The Northern province of Ha Tay presents VND 50,000 - 100,000 [USD 3.2 - 6.4] to each informer, while the southern province of Tien Giang gives raisers VND 15 000 [USD 1] for each fowl culled, instead of VND 5000 [USD 0.3] as it did previously. In addition to policy measures, Viet Nam is intensifying propaganda via mass media. Local residents are urged not to throw dead fowl away and not to have direct contact with poultry. People with symptoms of fever, runny nose, cough and exhaustion are advised to go to health care facilities as soon as possible. The Ministry of Agriculture and Rural Development reported on 22 Jan 2005 that bird flu has spread to 232 communes in 23 cities and provinces nationwide (additional 23 communes in 9 cities and provinces), with > 500,000 chickens, ducks and quails being culled. After Hanoi and Ha Nam, Hai Duong is the 3rd locality in the northern region to be affected by bird flu. In central Quang Nam province, bird flu has spread to 7 communes and wards : 60 out of 124 test samples showed positive for H₅N₁. Bird flu continues to spread throughout the country, with the latest outbreaks reported in Vinh Long, Dak Lak and Hai Phong provinces. In the Central Highlands province of Dak Lak, the outbreak was reported in a poultry breeding farm in Krong Nang district, with nearly 100 poultry head dead or destroyed. Meanwhile, > 200 sick ducks and chickens at a poultry breeding farm in Tan Phong commune, Thuy Nguyen district, in northern Hai Phong city, were killed after showing signs of bird flu symptoms. Southern Soc Trang province has also reported the 1st outbreak in My Xuyen district since the flu recurred in the Mekong River Delta in December 2004. Test samples taken from a local farmer's flock of 18 chickens proved positive to avian H₅ type A virus. Other test samples on 4 flocks of ducks in My Xuyen and Thanh Tri districts were also positive to H₅. In Quang Nam province, the flu is spreading to 7 communes and wards of 6 districts along National Highway 1A. Dead poultry have been also reported in Da Nang city in the past 2 weeks. 90% of a farmer's chickens in An Hai Tay, Son Tra district died, and he buried them on land in front of his house without any treatment. Meanwhile, thousands of households in Tien Giang, Long An, Can Tho and Bac Lieu provinces are suffering from heavy losses, after the flu hit the Mekong River Delta. Activity at the poultry market seemed to grind to a halt, although the situation is still considered under control. None of these provinces have announced the epidemic yet. On 27 Jan 2005, bird flu was found in 17 more sites in 13 communes of 11 districts in southern Bac Lieu, Long An, Ben Tre provinces and Can Tho city, and northern Hai Duong province : a total of 3320 chickens, 4471 ducks and geese, and 2530 quail had been culled in these localities. Since the beginning of 2005, bird flu has broken out in 579 spots in 304 communes of 109 districts in 28 provinces and cities across the country, with a total of 213 486 chickens, 253 549 ducks and geese, and 361 570 quail having been culled. The southern provinces of Long An, Tien Giang, Bac Lieu and Ben Tre have been the most severely affected by the epidemic, with a range of 36-192 outbreak spots, while the other southern provinces of Binh Duong, Binh Phuoc, Quang Nam, Lam Dong and Ca Mau, and northern Ha Nam province have reported outbreaks in only 1-6 communes each. No new outbreaks of bird flu have been found in Ha Nam and Binh Phuoc provinces over the past 18 days (since 9 Jan 2005), nor in Hau Giang, Ca Mau and Dong Thap provinces over the past 16 days (since 11 Jan 2005). On 28 Jan 2005, an additional 29 bird flu outbreaks were reported in 16 communes of 10 districts in the provinces of Hai Duong, Bac Ninh, Bac Lieu, Long An, Ben Tre, Dong Nai, and Can Tho City. From 1-28 Jan 2005, bird flu outbreaks occurred in 116 districts of 30 cities and provinces nationwide. A total of 225 690 chickens, 289 590 ducks and geese, and 381 850 quail were culled. Only 2 new outbreaks of bird flu were reported from 2 communes in the southern provinces of Dong Thap and Ben Tre on 9 Feb and in the morning of 10 Feb 2005. A total of 1050 ducks and geese were culled. However, no new outbreaks of bird flu have been reported in northern Ha Nam province or southern Binh Phuoc province since 9 Jan 2005, and in Ninh Thuan and Lam Dong provinces since 20 Jan 2005. Since its initial emergency report to the OIE regarding the 1st recorded HPAI outbreak, on 9 Jan 2004, Viet Nam has sent 12 follow-up reports; 11 of them during 2004: 30 Jan, 27 Feb, 19 Mar, 14 May, 2 Jul, 16 Jul, 23 Jul, 24 Sep, 22 Oct, 26 Nov and 24 Dec 2004. A single report has, so far, been received by the OIE in 2005; this was the 12th follow-up report, sent 4 Jan, circulated 7 Jan 2005. All said reports can be seen in OIE's last (21 Jan 2005)^ref . Vietnam had about 208 million poultry in December 2004. Since the start of the latest outbreak > 1.4 million birds have been killed, only 1/10 of those culled during the 1st epidemic which began in parts in Asia in December 2003. AI, which has killed and led to the forced culling of more than 1.5 million fowl in 35 cities and provinces in the country since January 2005, is cooling down. By Sat 26 Feb 2005, 14 out of 35 provinces and cities had detected no new bird flu-affected sites for at least 3 weeks. These localities include Kien Giang, Ninh Thuan, Dong Nai, Tien Giang, HCM City in the south, Quang Binh, Nghe An in the centre, Lam Dong in the Central Highlands, Ninh Binh, Ha Nam, Thai Nguyen, Phu Tho, Thai Binh and
Hanoi in the north. However, on Fri 25 Feb 2005, 11 new infection hotspots were detected at poultry farms in 9 communes of 8 districts of the Cuu Long (Mekong) Delta provinces of Bac Lieu, Long An, Dong Thap, Ben Tre and Tra Vinh. As of 26 Feb 2005, 6000 ducks and geese have been culled in the communes as part of an eradication programme. On Wed 27 Apr 2005 the Anti-Bird Flu Committee ordered a ban on the hatching of all water fowl eggs until February 2006 and ordered a mass cull of all 1.5 million water fowl carrying the H₅ component of the H₅N₁bird flu virus in the Mekong Delta city of Can Tho. Viet Nam decided earlier in 2005 to ban the breeding of ducks until 30 Jun 2005, and in February Ho Chi Minh City ordered a cull of all ducks. The current decision, extending the policy for almost a year, is in line with the recent FAO/OIE conclusions, namely that "control of HPAI should be carried out at source, managing transmission of the virus where the disease occurs in poultry, specifically free-range chickens and in wetland dwelling ducks". The feasibility of such a far-reaching decision remains to be seen. According to agriculture figures, in Viet Nam there are an estimated 59 million ducks, geese and other waterfowl, most raised in open-air backyard farms.
After 2 months with no reports of large bird flu outbreaks, health workers slaughtered and buried > 6,000 chickens on Jun 20 at a farm in An Khanh commune in the province of Ben Tre in the Mekong Delta, 85 km (55 miles) southwest of Ho Chi Minh City, after the birds were found to carry the H₅ component of the bird flu virus. The tests were conducted after the farm owner reported that > 3,000 of his chickens had  died between June 9-11. Ben Tre is one of the areas where the virus first emerged in late 2003 then spread to the northern region where the virus appears to develop rapidly during the winter. The last reported large outbreak was in mid-April 2005, but smaller outbreaks have been continually occurring since then. Outbreaks, with large or small numbers of fowl, are still scattered throughout the country. Vietnam's last (13th) follow-up report to the OIE on avian influenza was sent on 28 Feb 2005 : a fresh report will be welcomed.
A cross-sectional seroprevalence survey among 83 hospital employees exposed to 4 confirmed and one probable H₅N₁ infected children, 4–12 years of age, or their clinical specimens from December 27, 2003 to January 19, 2004 at the National Pediatric Hospital (NPH), Hanoi^ref, Vietnam showed no study participants had detectable antibodies to influenza A (H₅N₁) virus. A number of possible factors may explain these findings: a lack of infectivity of the patients at the time of admission; the effective use of personal protective equipment (PPE) and infection control; low sensitivity of the antibody detection method; lack of susceptibility of HCWs, or a lack of transmissibility of this particular H₅N₁ strain. No data are available on the duration of H₅N₁ virus shedding in children. However, for human influenza virus, viral shedding at high titers is generally more prolonged in children, and virus can be recovered up to 6 days before and 21 days after the onset of symptoms. The H₅N₁ patients in this study were admitted with severe illness 3-7 days after onset of symptoms, and PCR-positive specimens were obtained from the 4 confirmed case-patients on day one (one patient), day 2 (one patient), and day 3 (2 patients) after admission. In addition, live virus was cultured from samples taken from 2 of the patients on days one and 3 after admission, respectively. None of the patients were treated with oseltamivir, because this was not available at the time. 2 of the patients were treated orally with the nucleoside analogue ribavirin during their admission, one on day 4 after admission, and the other on day 1^ref. However, the 2 other confirmed case-patients and the probable case-patient did not receive antiviral treatment and, if human infection with H₅N₁ is associated with viral shedding, these patients would be expected to be contagious during their admission. Most hospital employees (94.8%) reported that they always wore masks while caring for H₅N₁ patients, and, often, the reported type of mask was an N95 respirator. However, N95 respirators were 1st available in NPH on 7 Jan 2004, and some employees reported wearing N95s before this date. Therefore, reported PPE use in this study may be biased by inaccurate recall or a tendency to report behavior that HCWs know is recommended. Enhanced infection control practices and PPE were instituted on 7 Jan 2004, and the diagnosis of AI was 1st confirmed on 9 Jan 2004. Therefore, some HCWs in this study were likely exposed to H₅N₁ patients without optimal PPE or infection control. Oseltamivir prophylaxis was not used by any of the staff in this study and therefore did not play a role in protecting HCWs. Whether the HCWs in the study were protected by cross-reactive immunity to other influenza A subtypes is hard to assess. One possible explanation for the observation that most confirmed H₅N₁ case-patients are reported in children or young adults is that older adults are protected by cross-reactive immunity from previous exposure to other influenza A viruses. This hypothesis requires further investigation. Serum samples were taken from HCWs at least 29 days after last possible exposure and at a time when the antibody response to exposure would be expected to be detectable. Based on a small number of samples, the sensitivity of a microneutralization test in detecting antibodies to H₅N₁ in children and adults is 88% and 80%, respectively, while the specificity is 100% and 93%, respectively^ref. Also, the microneutralization assay utilized H₅N₁ strains isolated from human patients in North Viet Nam, so the negative results are unlikely to be false negatives due to a poor match between antigen and antibody^ref. False-positive results are perhaps more likely, and one sample was initially positive but appeared to be due to cross-reacting anti-N₁ antibody.
Neighbouring countries like Cambodia, Laos, and Myanmar do not have the infrastructure or capacity at this stage to do the kind of surveillance that is necessary. In the past 2 days, outbreaks were reported in Ninh Binh, Phu Tho and Hai Phong in the north. In Ninh Binh province, the virus was detected in a flock of 10 chickens owned by a farmer in Ninh Xuan commune, Hoa Lu district. In Phu Tho province, samples taken from a flock of 100 chickens from Dong Thinh commune, Yen Lap district, tested positive for H₅N₁. Outbreaks were also reported in Kien Thuy, Vinh Bao and An Lao districts of Hai Phong city, with nearly 450 chickens and ducks dying or being destroyed. As a result, since 1 Jan 2005, bird flu has been found in 9 northern provinces, namely Ha Nam, Ha Noi, Hai Duong, Thai Nguyen, Bac Ninh, Thai Binh, Phu Tho, Ninh Binh and Hai Phong city. In the south, 15 more locations in Bac Lieu, Long An, Ben Tre and Dong Thap provinces reported bird flu on 29 Jan 2005. In Bac Lieu province, the virus was detected in 4 communes of Gia Rai and Phuoc Long districts. Meanwhile, the number of flu-hit spots in Long An province fell by half, to 3 households in Tan Tru district and Tan An town. Southern Hau Giang province has decided to subsidize farmers whose poultry were killed due to the flu. They will receive between VND 5000-6500 [USD 0.32 - 0.41] and VND 1000 [USD 0.063] for each poultry and quail killed, respectively. The province will assist households to buy new breeds at a reasonable price of VND 2000 [USD 0.13] each. Hanoi's 1st quarantined slaughterhouse was inaugurated on Monday and will begin operations on 1 Feb 2005 at the wholesale Long Bien market. With a total investment capital of VND 600 million [USD 38 000], the slaughterhouse is designed to slaughter quarantined poultry and wrap, seal and provide safe products for sale to local consumers. HCM City on 30 Jan 2005 announced that it will purchase more than 200 000 chickens to kill and reserve to minimize the risk of spreading the disease. 2/3rds of chicken breeders at a meeting on 30 Jan  welcomed the initiative, as they complained that they have found it difficult to sell their products on the market even though they are flu free. Ho Chi Minh City, Vietnam's largest city, home to 10 million people, within Feb 7 will slaughter 150,000 out of its 210,000 ducks to try to stop the renewed spread of bird flu, while a private firm will process 60 000 ducks for consumption : animal health officials said last week 31 of 148 samples taken from ducks in the city showed the presence of the virus. The European Commission, on Tue 1 Feb 2005, pledged to offer Vietnam 600,000 euros [nearly 788 000 US dollars] for the country's purchase of first-aid and experiment equipment to deal with human bird flu infections. Ho Chi Minh City plans to exempt hospital fees for bird flu victims, since daily treatment costs each patient up to 2-3 million Vietnamese dong [127 to 191 dollars]. In a move to curb the spread of bird flu, the municipal authorities have already decided to stop raising fowls, including fighting cocks, in its urban districts from 6 Feb 2005, and to halt the raising of ducks city-wide for one year from 7 Feb 2005 after turning live ducks into frozen meat and culling affected ones. No new bird flu outbreaks have been reported in 7 provinces across the country since Jan 20 to Feb 13, namely Ha Nam, Binh Phuoc, Ninh Binh, Kien Giang, Ninh Thuan, Lam Dong and Ho Chi Minh City. The provinces of Ha Nam (in the north) and Binh Phuoc (in the south) have reported no new outbreaks since Jan 13 to Feb 13. However, the disease still broke out on a scattered basis in some localities, with the latest outbreaks reported in Long An, Bac Lieu, Hai Duong, Hai Phong and Long An. Nearly 7000 chickens, ducks and quail have been culled. Phitsanulok officials have ordered the closure of 38 cockpits until April 2005 to prevent the transportation of fowl, in a bid to tackle a bird-flu outbreak in the province : the outbreak is mainly confined to domestic fowl, and the province is well known for its fighting cocks. Random bird-flu tests found the virus in up to 70% of domestic fowl, a result of the transportation of fighting cocks. Meanwhile, tambon sub-district Matume residents in the province's Phrom Phiram district on 11 Feb 2005 agreed to the culling of 200 chickens and will continue efforts to eradicate bird flu. By 21 Feb 2005, no new outbreaks have been found in 12 out of 35 bird flu-affected provinces and cities in Viet Nam in the past 21 days. The provinces and cities free from the outbreak include Kien Giang, Ninh Binh, Ha Nam, Binh Phuoc, Ninh Thuan, Lam Dong, Quang Binh, Thai Nguyen, Nghe An, Dong Nai and Tien Giang provinces, and Ho Chi Minh City.
No new outbreak has been reported since Apr 2 2005, but initial testing has shown on 13 April 2005 that 71% of ducks and 21.4% of chickens in Viet Nam's 11 southern localities in the Mekong Delta are infected with bird flu virus strain H₅. Up to 80% of 2000 samples taken from ducks raised in Can Tho city alone, which is home to some 1.5 million poultry, tested positive to H₅. On 1 Apr 2005, Viet Nam started a month-long campaign to clean up poultry farms nationwide in a move to stamp out bird flu, which has hit 35 cities and provinces nationwide since January 2005. 33 localities have so far detected no new affected spots in their territory for 3 weeks, meeting the country's criteria to announce an end to the disease. Viet Nam has reported 35 human cases of bird flu infection since December 2004, of whom 16 have died. The role of ducks as reservoir of infection in Eastern Asia has been addressed during the recent FAO/OIE consultation, which concluded that the possibility of vaccinating ducks should be explored. Experimentally, vaccines have been shown to significantly reduce AI virus replication and shedding in domestic ducks and geese and thus decrease environmental contamination (especially in ponds, lakes and rivers) and prevent contact transmission. Last known outbreak: 29 Mar - 4 Apr 2005. A total of 1300 ducks have either died or been culled in Tra Vinh Province.
On 19 Apr 2005, a ban on poultry farming in Vietnam's urban areas was extended from Ho Chi Minh City to 15 cities and urban areas (Hanoi, the central cities of Hue and Danang Provinces, Quang Ninh Province, and Can Tho Province), and other measures were announced such as closure of small markets dealing in live poultry in urban areas to be replaced by big slaughterhouses; isolation of fowl production establishments from residential areas; a ban on hatching and raising waterfowl extended from 30 Jun 2005 to the end of 2005; and restriction on the freedom of local farmers to breed waterfowl in fields. Trials of inactivated vaccines are currently being carried out, and a trial with 600 000 doses of a recombinant vaccine has been approved in HCMC. A pilot vaccination in 2 provinces (southern Tien Giang and northern Nam Dinh) is planned for July and August 2005. Based on the outcome of the trials, a nationwide vaccination strategy will be designed and a targeted vaccination countrywide will be considered for October 2005. The Health Ministry asked the government to invest in building 2 more bird flu testing laboratories, which cost some VND 80 billion (USD 5.1 million). The United Nations Food and Agriculture Organization (FAO) has pledged to fund Viet Nam USD 4 million to build the laboratories and USD 2.5 million to redevelop its poultry sector.
No new outbreak of HPAI has been reported since 2 Apr 2005. But of more than 10 000 random duck and geese samples gathered from poultry farms
across 10 Mekong Delta provinces, 71% tested positive so far in 2005. The virus was found in about 26% of duck samples. A Vietnamese study which showed an H₅N₁ prevalence rate of 70% when ducks and chickens were raised together, compared to 8% for chickens raised separately.
WHO Inter-country consultation - Influenza A/H₅N₁ in Humans in Asia - Manila, 6-7 May 2005 : some important epidemiological features of human H₅N₁ infections occurred in northern Viet Nam during January through April 2005 and appeared to differ in some respects from those seen in 2004 in other parts of Asia, and in the concurrent period in southern Viet Nam. These included :
• an increase in the number of case clusters in the north (8) compared with the south (2)
• a prolonged interval between the 1st and last cases in clusters, signaling a growing number of ways in which people contract the virus, including exposure to sick birds, environmental infection, lengthy exposure to asymptomatic birds that are shedding virus, and person-to-person transmission.
• the case-fatality rate has dropped to 34% this year in the north but is 83% in the south. In addition, the report says the recent discovery of 3 asymptomatic cases in Vietnam suggests that milder infections are occurring. A few asymptomatic cases also were found in Japan and Thailand in the past year, and others were discovered in Hong Kong after the H₅N₁ outbreak in 1997.
• an expanded age range of cases and fewer fatal cases. The average age of infected people in northern Vietnam rose from 17 to about 31 years between 2004 and 2005, but it stayed about the same in southern Vietnam (15 to 18 years)
The AI virus had already vaulted to the top of the pandemic threat list because it had developed the ability to sicken and kill humans. The virus's inability to cause efficient, ongoing human-to-human transmission is the last barrier to a pandemic. Now experts appear worried that the barrier is crumbling. "Investigators were not able to prove that human-to-human transmission had occurred. However, they expressed concerns, which were shared by local clinicians, that the pattern of disease appeared to have changed in a manner consistent with this possibility," the assessment states. At the same time, it says that in places where the disease in poultry has been controlled or eliminated, human cases have stopped. And thus far, the 1st case in most of the human clusters in Vietnam followed the person's exposure to infected poultry. For now, prevention of H₅N₁ avian influenza in humans is best achieved by controlling infection in poultry. As already recommended by FAO and OIE, control strategies for this disease should consider vaccination of poultry, which has been used successfully before. A team of WHO expert consultants studied Vietnam's outbreak at that country's request from Apr 15 through 25 : that study showed H₅N₁ could be changing more in the northern region, which prompted a 2nd expert consultation. The experts make a number of recommendations, including increasing efforts to improve risk assessment, to boost the ability of affected countries to address outbreaks, and to speed the pace of pandemic planning. The 14 recommendations include the following:
• WHO should convene its Pandemic Task Force to meet regularly, assess the data, and determine the risk for pandemic flu
• all nations should move as quickly as possible to complete "practical operational pandemic preparedness plans."
• WHO should explore "all possible mechanisms" to make H₅N₁ vaccine available to the Asian countries affected before a pandemic. It should bring together technical experts, countries, manufacturers and possible donors to find ways to boost global H₅N₁ vaccine production
• coordination of animal and human surveillance and viral information must be improved from the ground level to the national and international level, and data must be exchanged quickly
• the WHO should complete a handbook on how to investigate possible H₅N₁ clusters
• the WHO should explore building a stockpile of antiviral drugs that could be used to respond to early signs of a potential pandemic
• countries needing funding and agencies that may provide funding must coordinate their efforts to avoid redundancy and eliminate gaps.
Evolution of a pandemic strain of virus may be preceded by numerous small steps, none of which is sufficient to signal clearly that a pandemic is about to start. This poses a difficult public health dilemma. If public health authorities move too soon, then unnecessary and costly actions may be taken. However, if action is delayed until there is unmistakable evidence that the virus has become sufficiently transmissible among people to allow a pandemic to develop, then it most likely will be too late to implement effective responses.Investigators were not able to prove that human-to-human transmission had occurred. However, they expressed concerns, which were shared by local clinicians, that the pattern of disease appeared to have changed in a manner consistent with this possibility. These differences suggest that the epidemiology of H₅N₁ infections may be evolving in Asia. The changes in epidemiological patterns are consistent with the possibility that recently emerging H₅N₁ viruses may be more infectious for humans. Furthermore, sequencing analyses of H₅N₁ genes from avian and human H₅N₁ viruses from several countries suggest that they are becoming more antigenically diverse and may be forming distinguishable groupings based on phylogenetic analyses. While the implications of these epidemiological and virological findings are not fully clear, they demonstrate that the viruses are continuing to evolve and pose a continuing and potentially growing pandemic threat. Based on these concerns and findings, it would be prudent to take increased steps to improve risk assessment procedures, to strengthen the ability of affected countries to respond promptly to local outbreaks, to accelerate control of avian influenza in poultry and to implement or complete pandemic preparatory actions as soon as is possible, even if current H₅N₁ outbreaks in Asia cease or diminish during the summer^ref. That led the WHO to consider upgrading the pandemic threat level from 3 (on a 6-point scale) to 4 (small, localized clusters of human infection) or 5 (large clusters of infection) -- just one step away from a full-blown global pandemic. But first it asked an international team of experts, including Masato Tashiro, a virologist at the National Institute of Infectious Diseases in Tokyo, to retest many of the samples and some new ones, using the WHO's own PCR tests : a WHO team that included experts from Australia, Canada, Hong Kong SAR, Japan, the United Kingdom, and the USA stayed in Vietnam since Jun 21 to 28 using using WHO-approved reagents and primers. They found that the H₅N₁ avian influenza virus in Vietnam has not recently improved its ability to spread to or among humans and did not find evidence of previously undetected asymptomatic or mild human cases of H₅N₁ infection^ref. Samples have now been sent to a WHO laboratory in Hong Kong for the last word in confirmation: antibody neutralization assays. Pushing the level to 4 for the first time would mean deploying the international stockpile of antiviral drugs to try to contain or stamp out the spread, and would probably result in countries restricting travel to Viet Nam.
On 29 Jun 2005 Vietnam announced it will begin vaccinating poultry nationwide against bird flu since 1 Aug 2005 at commercial poultry operations and smaller household farms in northern Nam Dinh province and southern Tien Giang province in the Mekong Delta. Vaccinations will be slowly expanded to another 40 high-risk provinces in the next 2 years. An initial 20 million doses of vaccines will be imported from the Netherlands and China. The 2-year poultry vaccination program will cost 35 million USD. The government will subsidize 29 million USD and the rest will come from fees charged to large commercial operators. Household farmers will get their chickens vaccinated for free. If the plan outlined above is realised, Viet Nam will become Asia's 3rd country which officially applies vaccination against HPAI, following China and Indonesia. Details on the candidate vaccines, the vaccination scheme including species (waterfowl in addition to chickens?) and age of the vaccinees, and the laboratory-backed follow-up, if contemplated, will be helpful. Vietnam will use over 400 million batches of vaccine to inoculate its chickens and ducks against the deadly bird flu. The Chinese vaccine against the H₅N₁ virus, which international health officials fear could mutate into a form which might trigger a human pandemic, would be used on ducks. A Dutch vaccine against the H₅N₂ virus, a less virulent strain which is not widespread in Vietnam, will be used on chickens.
Up to 70% of waterfowl in Viet Nam's southern Mekong delta have tested positive for the bird flu virus strain H₅N₁. Local veterinary agencies culled 4620 poultry, mainly ducks and chickens, after they detected small outbreaks of bird flu in the capital city Hanoi and the 3 southern localities of Can Tho, Ben Tre
and Dong Thap in July 2005. To minimize possible new outbreaks, Viet Nam is vaccinating chickens and ducks in northern Nam Dinh province and southern Tien Giang province against bird flu viruses, including H₅N₁, on a trial basis. It will vaccinate some 43 million poultry, including chickens, ducks, geese and doves, within several months. Officials and volunteers on Sat 30 Jul 2005 began giving about 91 000 injections in parts of Tien Giang province and started vaccinating another 2.9 million birds on Mon Aug 1. Nam Dinh province was set to begin its trial vaccinations Thu 4 Aug 2005 and will immunize 4.2 million birds next week.
Animal health authorities in the Mekong Delta province of Ben Tre recently killed more than 400 fowls infected with the deadly H₅N₁ bird flu virus at a local farm. Animal health officials have disinfected neighboring farms and areas where the virus was detected. The province has reported 2 recurrences of bird flu so far, culling > 16 700 fowls. Viet Nam's last (4^th) HPAI follow-up report to the OIE was sent on 27 Jun 2005, relating to one outbreak in Ben Tre province that started 10 Jun 2005. Reportedly, the causative agent was identified by PCR as highly pathogenic avian influenza virus type H₅^ref. A new follow-up report might be expected. Viet Nam was planning to start mass vaccinations against HPAI in August.  Reportedly, vaccinations will begin 1 Aug 2005 at commercial poultry operations and smaller household farms in northern Nam Dinh province and southern Tien Giang province in the Mekong Delta.
On Fri 26 Aug 2005, officials said samples sent to a lab in Hong Kong from 3 rare Owston palm civets (Chrotogale owstoni) born in captivity at the Cuc Phuong National Park, about 120 km south of Hanoi, and died in late June 2005, came back positive for the H₅N₁ virus, marking the 1st time the virus has been reported in the species. Other animals at the park have been tested -- including chickens, rats and other birds -- but none have tested positive for the virus. The civets were not fed any type of poultry, and 20 other civets of the same species in adjacent cages did not become sick. The World Health Organization and Viet Nam health officials are expected to test staff and animal keepers to determine whether anyone caring for the civets has been infected with bird flu. Cat-like civets are captured in the wild and served as a delicacy at restaurants in Viet Nam and China. Scientists suspect that SARS was passed to humans from civet cats and other mongoose-like animals sold in live food markets in southern China. The development would not make people more susceptible to bird flu, because humans have less contact with civets than with poultry. Bird flu had previously been found in other mammals, such as cats and tigers. The genotyping of the causal agent recorded in the civets, and its comparison to previous isolates of H₅N₁ strains from mammals, are expected with interest. Studies of H₅N₁ infection of pigs (mammals of particular significance in relation to the epidemiology of avian influenza in respect to human health) using viruses isolated in Viet Nam and Thailand have recently been published (Young Ki Choi, Tien Dzung Nguyen et al. Journal of Virology, August 2005, p. 10821-10825 Vol. 79, No. 16). This is an interesting report; but perhaps not so surprising. Other members of the order Carnivora are know to be susceptible to avian influenza viruses. Family Felidae - both domestic cats (H₇N₇) and zoo tigers and leopards (H₅N₁) have suffered infection and the H₅N₁ virus was transmitted among zoo tigers. Family Mustelidae - the ferrets, badgers, skunks, etc. Ferrets are highly susceptible to influenza viruses. The first human influenza virus was isolated by Wilson Smith and Stuart-Harris by inoculation of patient material into ferrets in the 1930's. Ferrets are still the animals of choice for production of diagnostic antisera (e.g. see the WHO statement "Evolution of H₅N₁ Avian Influenza Viruses in Asia" by The World Health Organization Global Influenza Program Surveillance Network^ref).
According to local veterinary agencies, up to 70% of waterfowl in the southern Mekong delta have recently tested positive to H₅N₁ virus. Viet Nam has culled over 1300 fowl in 8 localities of Dong Thap, Ben Tre, Can Tho, Tra Vinh, Yen Bai, Ha Giang, Bac Ninh and Hanoi since early April 2005. The
country is conducting bird flu vaccination for [domestic] fowl, mainly chickens and ducks, in 47 out of 64 cities and provinces. The total fund for vaccinating over 200 million fowl in the 2005-2006 period is estimated at 700 billion Vietnamese dong (44.3 million US dollars).
110 out of over 300 ducks raised by a local farmer in Hong Dan district in southern Bac Lieu province died on Oct 2005 : the whole flock, which had yet to be vaccinated against bird flu, was culled Tue 18 Oct 2005 morning. Bac Lieu has vaccinated > 600 000 fowl out of its poultry population of over 1.1 million. The Vietnamese government has recently decided to spend 700 billion Vietnamese dong (VND) (USD 44.3 million) on vaccinating fowl. Viet Nam is importing more bird flu vaccines from China so as to complete the 1st batch of vaccination by late Nov 2005. All fowl will have been vaccinated by late March 2007. To date, 37 out of 64 cities and provinces have vaccinated over 54 million fowl. Viet Nam has detected 22 bird flu outbreaks in 10 provinces since April 2005, which have killed and led to the forced culling of nearly 14 400 fowl. To deal with possible bird flu outbreaks among humans in the coming time, the government will upgrade hospitals and ensure sufficient reserves of anti-virus drugs with an estimated cost of some 6870 billion VND (nearly USD 434.8 million)
On Nov 10, 2005 it was reported that 300 ducks died in the central province of Quang Nam, and animal health workers slaughtered another 1000 while tests for bird flu were still underway. 15 ducks died on Tue 8 Nov 2005 in the northern province of Bac Giang, where > 134,000 chickens, ducks and geese were slaughtered last week during its 1st outbreak this winter.
The Youth newspaper reported on Sat 12 Nov 2005 that results of the Viet Nam's Ho Chi Minh City Pasteur Institute research on 24 virus samples from infected poultry and people in the southern region between December 2003 and March 2005 show there are some changes in gene segments coding for the surface antigens HA and NA and some other gene segments of the H₅N₁ virus in Viet Nam in early 2005. The changes indicate that the virus has been mutating to reproduce effectively in cells of mammals and increase its attacking capability. All the viruses researched by the institute in southern
Ho Chi Minh City are resistant to the 2 antiviral medicine agents amantadine and rimantadine. The study also found a mutation of the PB2 gene in a virus sample from a patient who died in the southern Dong Thap province earlier in 2005. The finding showed the virus had been combining changes to adapt to new hosts^ref. New avian influenza strains of the H₃ and H₄ subtypes were found in poultry : there was also the risk of these subtypes mixing and exchanging genetic material with the H₅N₁ virus. There would then be the possibility of the H₃N₄ and H₄N₅ strains becoming more pathogenic.
30 black cormorants in a bird sanctuary in Gao Giong, in Vietnam's southern Dong Thap province suddenly died on 15 Nov 2005, prompting the local authorities to close all wild bird eco-tourism sites in the Mekong Delta, including Tram Chim national park, the stork garden of My An, and the 2 eco-tourism sites of Gao Giong and Xeo Quyt, to prevent potential bird flu spread to humans as well as protect the birds. There are 3 species of cormorant in Indochina: little cormorant, Phalacrocorax niger; Indian cormorant, Phalacrocorax fuscicollis; and great cormorant, Phalacrocorax carbo. Each of these appears to be resident in neighbouring Cambodia, although other populations of great cormorants are known to be migrants. Indian cormorant is the commonest of the 3 in Cambodia. Great cormorants have been mentioned as one of the species found infected with HPAI H₅N₁ in Lake Qinghai, northern China, in May 2005. Recently, Vietnam's 2 biggest cities, the capital Hanoi and Ho Chi Minh City in the south, ordered residents of their inner areas not to raise ornamental birds as of 15 Nov 2005 and 30 Nov 2005.
Since 1 Oct to 25 Nov 2005, bird flu has been detected in 85 communes in 17 provinces and cities (Bac Giang, Quang Nam, Thanh Hoa, Hai Duong, Hung Yen, Ninh Binh, Hai Phong, Quang Ngai, Vinh Phuc, Bac Ninh, Son La, Hoa Binh, Thai Binh, Phu Tho, Thai Nguyen and Cao Bang in the northern and central regions, and Long An in the southern region), killing and leading to the forced culling of nearly 900 000 fowl. Over 154 million poultry turns (each dose for a fowl being considered one turn, two doses for the same fowl regarded as two turns) have been vaccinated so far in the country.
On 5 Dec 2005 4 bird flu outbreaks have killed > 900 ducks and chickens in the northern Cao Bang province (270 km (170 miles) north of Hanoi,
bordering the Chinese southern province of Guangxi) and health workers slaughtered another 3717 birds.
On 8 Dec 2005 2 bird flu was reported in 2 more provinces in Vietnam; Yen Bai Province in the northern mountainous region and Quang Tri in the centre. The latest outbreak killed 500 ducks in a household in Quang Tri's Gio Linh District late in November 2005, forcing the farmer to cull a total of 5000
birds. The department also said that avian flu has been detected in a number of poultry farms in Son La, Thanh Hoa and Ninh Binh provinces, all previously hit by outbreaks. The outbreak has now affected 15 provinces and cities in Vietnam, while 5 provinces have since been declared free of bird flu after not seeing
outbreaks for 21 days.
Central  Quang Tri Province and northern Bac Ninh Province announced on Dec 19 that they were free of bird flu after 21 days with no cases reported. So far, 9 provinces have met conditions set by local health authorities to qualify as free of the virus, including Bac Giang, Hoa Binh, Thai  Binh, Hung Yen, Long An, Hai Duong, Phu Tho, Quang Tri, and Bac Ninh. 67 communes of 37 districts in 12 provinces still officially have animals infected with bird flu: Cao Bang, Ninh Binh, Son La, Thai Nguyen, Hai  Phong, Vinh Phuc, Quang Ninh, Yen Bai, Ha Giang and Bac Kan in the north and Thanh Hoa and Nghe An in the central region. Since 1 Oct 2005, nearly 3.65 million fowl have been culled. By 19 Dec 2005, 15 provinces had completed the 2nd cycle of vaccinations for 71.5 million fowl, 28 are preparing for the 2nd round and the remaining provinces are vaccinating their poultry for the 1st time^ref.
A population-based study was performed from April 1 to June 30, 2004, in FilaBavi, a rural Vietnamese demographic surveillance site with confirmed outbreaks of highly pathogenic avian influenza among poultry. 45 478 randomly selected (cluster sampling) inhabitants were included. Household representatives were asked screening questions about exposure to poultry and flulike illness during the preceding months; individuals with a history of disease and/or exposure were interviewed in person. A total of 8149 individuals (17.9%) reported flulike illness, 38 373 persons (84.4%) lived in households keeping poultry, and 11 755 (25.9%) resided in households reporting sick or dead poultry. A dose-response relationship between poultry exposure and flulike illness was noted: poultry in the household (odds ratio, 1.04; 95% confidence interval, 0.96-1.12), sick or dead poultry in the household but with no direct contact (odds ratio, 1.14; 95% confidence interval, 1.06-1.23), and direct contact with sick poultry (odds ratio, 1.73; 95% confidence interval, 1.58-1.89). The flulike illness attributed to direct contact with sick or dead poultry was estimated to be 650 to 750 cases. These epidemiological data are consistent with transmission of mild, highly pathogenic avian influenza to humans and suggest that transmission could be more common than anticipated, though close contact seems required. Further microbiological (serological) studies are needed to validate these findings^ref.
On Feb 22, 2006 the first round of chicken & duck vaccination has been completed in all provinces and cities nationwide; 246 million doses of vaccines have been used. Post-vaccination surveillance has been implemented, and 10,102 serum saples have been tested so far with protection rate > 80%. For antigen detection, 1500 swab samples have been collected; the results were all negative.
On Thu Apr 6, officials said the H₅ subtype virus was found in samples from chickens smuggled from China and seized in Lang Son province, marking the first published finding of bird flu in poultry in Vietnam since December 2005. 30 birds died on 19 Mar 2006 on 3 farms in Trung Khanh district (an area afflicted by bird flu in 2005) in Cao Bang province, near to Lang Son and 270 km (167 miles) north of Hanoi^ref : samples for testing sent on 25 Mar 2006 tested positive for H₅ and 157 chickens and ducks were slaughtered on Apr 8. No further tests will likely be done to confirm if the strain was H₅N₁. Cao Bang province would vaccinate poultry against bird flu later this month. Northern Vietnamese were involved in the lucrative illegal trade of smuggling chickens from China. They can sell the birds in Vietnam at up to 10 times their buying price but in the process run the risk of re-introducing bird flu^ref. Hopefully, all affected animals have been susceptible, unvaccinated birds. If vaccinated birds have been affected as well, this will become a cause for concern, requiring further investigations. Hired runners strap bamboo cages loaded with 20 live chickens onto their backs in China. Under cover of darkness, they navigate well-worn footpaths across a mountain into Vietnam, where bicycles wait to haul the clucking contraband away. The smugglers easily evade patrols along the rugged 1350-km (840-mile) border by using 2-way radios and a network of illegal crossings that have become gateways for a new threat: bird flu. Vietnam estimates that about 4500 chickens are trafficked into the country this way every day from China in a trade that is nearly impossible to police because of scarce resources. Vietnam has not detected any outbreaks in poultry for 4 months and no human cases have been reported since November 2005. Its success has boosted demand for poultry as more Vietnamese shed their fears of eating infected meat. That, in turn, has fueled the smuggling. Smuggled birds typically come from large Chinese farms where high volume and low feed prices keep overall costs low. The poultry can be resold in Vietnam for up to 5 times more, depending on the market. For instance, older chickens that no longer lay eggs can be bought by smugglers for about 14,000 dong (88 cents) per kilogram, and can end up in markets in Hanoi and other cities. In the Vietnamese border town of Lang Son, such birds fetch 37,000 dong (USD 2.34) a
kilogram  -- still 10 000 dong (63 cents) cheaper per kilogram than Vietnamese-farmed chicken. Vietnam will have to consider a regular poultry vaccination policy to protect itself^{ref1, ref2}.
• Thailand, which has never reported the disease previously : the official information obtained from the Delegate of Thailand to the OIE on 18 Dec 2003 indicated that the outbreaks in chickens were caused by a mixed infection of fowl cholera (Pasteurella multocida type A), and acute pasteurellosis (Pasteurella hemolitica) in the Nong Bua district, Nakhon Sawan Province. Since the outbreak began in November 2003 (but first official notification on 23 Jan 2004 !), the country expanded the number of bird flu crisis zones to 41 of the country's 76 on Jan 23, 2004 and culled > 36 million birds, mainly chickens but also broilers, layers, native chickens, ducks, geese, turkeys, ostriches, quail, and peacocks. Thailand's "red zones" are the 5-km (3-mile) areas around a confirmed outbreak within which all poultry must be slaughtered. Also 2 birds at Dusit Zoo and 10 city crows were infected. Location (Province) / Affected farms / Birds / Farms covered by stamping out / Birds destroyed

• Angthong / 1313/ 2 955 056 / 287 / 2 078 747
• Bangkok / 73 / 1 531 224 / ... / 1 057 685
• Chainat / 2 / 5764 / 2 / 5764
• Chaiyaphum province, districts of Kaset Sombun and Ban Kwa / 2
• Chonburi province, districts of Bo Thong, Ban Bung and Panus Nikhom / 3
• Kalasin / 7 / 24 958 / 81 / 95 960
• Kampaengphet / ... /  221 109 / ... / 220 745
• Kanchanaburi, districts of Huai Kajao and Nong preu  / 2863 / 1 196 263 / 1892 / 927 137
• Khon Kaen province, district of Muang
• Nakhon Pathom province, district of Muang / 242 / 601 132 / 10 / 65 150
• Phang Nga province, districts of Takua Pa, Takua Thung, Kapong and Tabput
• Phetburi province, district of Cha Um
• Phichit / 36 / ... / ... / 234
• Phitsanuloke / ... / ... / ... / 4380
• Ratchaburi / 15 / 439 900 / 9 / 198 780
• Roiet province, district of Kaset Pisai
• Sakonnakhon / 203 / 7017 / 203 / 7017
• Singburi / 45 / 657 775 / 7 / 302 575
• Sukhothai province, district of Si Samrong / ... / ... / 2 / 83 086
• Suphanburi / ... / ... / 850 / 4 706 323 (an outbreak began on 19 Jan 2004 in Banlam Sub-District, Bandplamah District, Supanburi Province in laying hens aged about 8 months in one ventilated house (traditional farming practice) : 8750 cases and 6180 deaths + 60 170 destroyed)
• Uthaithani province, district of Banrai / 1524 / 124 883 / 536 / 113 025
• Uttaradit province, district of Tron / 477 / 2 947 534 / 59 / 328 529
The second testing on Feb 21 2004 of 10,300 samples collected since 12 Feb from the red zones and 427 samples from the yellow zones (where movements of poultry were banned without a transport certificate) by 7 testing centers and one institution found the bird flu in 14 points in 10 provinces in the former red zones, and a new 9th province is Roi-Et in Thailand's northeast (where the flu came from "nomadic ducks" transported to open fields to graze for food such as snail pests). Officials are blaming fighting roosters smuggled out of red zones during the first outbreak and then brought back to the areas had probably re-ignited the 2nd wave of the epidemic. Thailand had declared itself free of bird flu on Mar 8 after no areas of Thailand have had active cases of bird flu in poultry since 25 Feb (> 1 month since the country's first case was reported : OIE allows the breeding of new chicken stocks 3 weeks after no new cases have been found, but the ministry decided to wait until April to ensure there are no new outbreaks) but on results dated Feb 26 confirmed bird flu in a poultry sample in Chiang Rai province, 420 miles north of Bangkok, and the disease is also suspected in Nakhon Ratchasima and Maha Sarakham. Deaths in 200 chickens were also reported in Chiang Mai Sansai district and > 20 000 chickens died in Uttaradit (Muang district ) on 11 Mar 2004. Thailand's hopes of declaring itself free of the bird flu virus were dashed again on April 9 after fresh outbreaks were detected in 2 provinces, Chonburi Province, Pangthong District, Nong Tumlung Subdistrict (April 7) and Khon Kaen Province, Muang District, None Ton Subdistrict (March 25) : both areas had recorded outbreaks of the deadly H₅N₁ strain of AI earlier in the year. Thailand was expected to declare the all-clear on Tue 27 Apr but the discovery last week of 3 new outbreaks in 2 provinces, involving 31 473 avians meant it had to be postponed for the fourth time, until 10 May. According to the report^ref, one outbreak involving a farm with 15 684 layers and 5 geese was recorded in northern Uttaradit province on Apr 19, while 2 outbreaks in 2 different subdistricts of the Petchaboon province involved 7584 and 8200 broilers (diagnosed on 21 Apr), respectively. Chickens account for 1% of Thailand's exports (the world's 4th largest poultry producer behind the United States, Brazil, and China, with annual exports worth USD 1.5 billion: 39% reaches Japan and 54% reaches the European Union; contributes about 1% to the country's GDP. About 81 000 families rely on the industry for a living. The industry employs hundreds of thousands of people on 30 000 poultry farms and in related industries, such as animal feed). Thailand's chicken exports will slide 21.9% in 2004 : exports of cooked chicken are expected to surpass exports of raw chicken in 2004. Cooked chicken exports will rise to 220 000 to 230 000 tons from 128 000 tons in 2003, while frozen chicken exports will fall to 170 000 tons from 380 000 tons. Chicken production in Thailand is still only about 40-50% of the normal rate.
• 12 laboratory confimed human cases : 8 have died
• a 6-year-old boy living in the central province of Kanchanapuri who developed fever on 6 Jan 2004 followed by severe pneumonia with ARDS a week later and was admitted to a public hospital in Bangkok; died on Jan 25
• a 6-year-old child from Sukhothai province; died on Jan 27
• a 58-year-old woman from the central province of Siphon Bury who died on Jan 28
• another 6-year-old boy - Nittikorn Chidnok - from Kanchanaburi province, died on Tue 2 Feb 2004. He developed illness on Sat 24 Jan 2004, was transferred on Jan 31 from a Nakhon Pathom hospital to Bangkok's Rajvithee Hospital after falling into a coma. The boy's mother said her son had suffered from a high fever since the Chinese New Year [22-24 Jan 2004] and been initially treated at Chao-khun Paiboon Hospital in Kancha-naburi but showed no signs of recovering. The boy was then moved to another hospital in Kanchanaburi before being transferred to Nakhon Pathom Hospital.
• a 7-year-old boy from Suphanburi province who developed fever and cough on 3 Jan 2004, progressed to acute respiratory distress syndrome (ARDS) on 13 Jan 2004, worsened and died on Feb 2
• a 13 year old boy from Chaiyaphum Province on 12 Feb 2004 died on 13 Feb
• a 2 year old boy from Suphanburi Province has fully recovered and has been discharged from hospital on Feb10
• a 27 year old woman from Uttaradit Provincehas fully recovered and has been discharged from hospital on Feb 10
• a 4-year-old boy from Khon Kaen Province died on 3 Feb 2004 and was confirmed on 18 Feb
• a 47-year-old woman from Lopburi Province who had exposure to diseased and dead chickens at her home in January 2004 fell ill with fever and cough on 3 Feb and was diagnosed with pneumonia on 20 Feb : hospital discharge followed 5 days later
• a 29-year-old man from Nakhon Ratchasima Province developed symptoms on 13 Feb 2004, was admitted to hospital on 20 Feb, and was discharged on Sun 7 Mar. He gave a history of exposure to diseased and dead chickens.
• a 39-year-old woman from Ayudhaya Province, a factory worker, developed symptoms on 1 Mar, was hospitalized on 3 Mar for diarrhea and died on Mar 12. About 20 infected fighting cocks raised by a neighbor had died in mid-February 2004
• a 31 yrs-old male from Nakornratchasima recovered
• tests at a Thai government laboratory that should have shown whether 14 more suspected human victims had contracted AI had been unsuccessful partly due to improper methods of collecting tissues and samples, despite 7 of the suspected victims have died. Thai authorities are currently investigating a further 147 reports of patients admitted to hospital with suspicious symptoms. Of these, 21 are being considered as suspect cases of H₅N₁ infection. All have a clinical diagnosis of pneumonia. 8 have died, 8 have fully recovered, and 5 remain hospitalized. The investigation of cases is following 3 lines: laboratory testing, epidemiological tracing of likely sources of infection, and examination of clinical features of disease. Final results of laboratory testing are pending for the additional 126 patients under investigation. The results of virus isolation studies are pending. These studies, which can take up to 14 days, are used to verify and supplement the initial PCR findings. :
• 6 deaths
• a Thai man in Chachoengsao province, 30 km (19 miles) east of Bangkok died on Fri 23 Jan 2004
• a 2-year-old girl from a southern province
• a 49-year-old butcher from Nakhon Sawan has suffered a high fever and severe pneumonia since 7 Jan 2004, occurring after the deaths of 70 chickens on his farm. He is in a private hospital in the Central Region and he is improving after antibacterial therapy
• a 2-year-old boy from Khon Kaen province, northeast of Bangkok
• a 67-year-old man from the central province of Chainat
In December 2003 2 tigers (Panthera tigris) and 2 leopards (Panthera pardus) died unexpectedly at a zoo in Suphanburi, after showing clinical signs including high fever and respiratory distress : histopathological and immunohistochemical evidence of AI A (H₅N₁) virus in leopard lung were found^ref. Tests confirmed that H₅N₁ had killed a rare clouded leopard (Neofelis nebulosa : an endangered subspecies in South East Asia) from Khao Khiew private zoo in Chonburi province, 70 km south of Bangkok on 27 January 2004. The most probably cause is raw chicken fed to the big cats. A white tiger (Panthera tigris) tested positive for the virus at the same zoo, but had recovered fully : tests are being carried out on > 200 cranes that died at Bungboraphet Bird Park in Nakhon Sawan province, 210 km north of Bangkok. AI A (H₅N₁) virus infection in 3 dead domestic cats (part of a single household of 15 cats owned by a Thai man living near an infected chicken farm in Nakorn Pathom, 37 miles (60 Km) west of Bangkok, of whose 14 died : 1 cat was still alive, but very sick and was being tested for H₅N₁) was announced on Feb 20 : 1 cat was observed by the owner to ate a chicken carcass on a farm where there was a bird flu outbreak, then disappeared and the remaining 14 became weak, started vomiting, and coughed blood before dying (3 were sent for necropsy, while the remaining 11 were buried by the owner, which is healthy but is being monitored because one of the cats used to sleep in her bed). Autopsies and virus tests were performed on the 3 cats at Kasetsart University's animal hospital and 2 cats tested positive for the H₅N₁ virus. The occurrence of H₅N₁bird flu in the domestic cats is due to eating raw chicken, proximity to infected farms and/or contact with infected bird carcasses. All the affected domestic cats would have had a high degree of exposure to the virus. Almost all cases of H₅N₁ bird flu in humans are traceable to infected chickens; though cats are susceptible to it, the virus does not appear to pose a danger to humans. Health Ministry officials were sent to check on anybody who had been in contact with the dead cats, while pet owners took immediate precautions, switching meals from cooked chicken to beef.
In early February 2004, a carcass of a 2-year-old male cat (Felis catus) was taken in an icebox 6 hours postmortem to the Faculty of Veterinary Medicine at Kasetsart University, Nakornpathom, Thailand. The cat's owner volunteered the information that the cat had eaten a pigeon (Columba levia) carcass 5 days before illness onset. The owner reported that the cat had a temperature of 41°C, was panting, and appeared to be depressed. Furthermore, the cat had convulsions and ataxia and died 2 days after onset of illness. The cat was given a single dose of 75 mg aspirin 1 day before it died; however, its body temperature remained elevated. Many dead pigeons were found in the area where the cat lived. Necropsy of the cat showed cerebral congestion, conjunctivitis, pulmonary edema, severe pneumonia, renal congestion, and hemorrhage in the intestinal serosa. Tissues from brain, trachea, lungs, mesenteric lymph nodes, intestines (duodenum, jejunum, and ileum), kidneys, liver, pancreas, spleen, and heart were collected, fixed with 10% buffered formalin, and processed for histopathologic examination. Histopathologic examination results showed nonsuppurative encephalitis, gliosis, mononuclear infiltration into the Virchow-Robin space, vasculitis, and congestion in both cerebrum and cerebellum. A microscopic lesion in the lung was caused by severe pulmonary edema, interstitial pneumonia, and congestion. Multifocal necrosis in the liver, tubulonephritis, and lymphoid depletion in the spleen were found. No abnormalities were detected in any other organs. The HPAI H₅N₁ isolate recovered from the infected cat's lung was labeled A/Cat/Thailand/KU-02/04. In addition, an isolate of HPAI H₅N₁ from an infected pigeon in the area where the cat lived was included in the study and labeled A/Pigeon/Thailand/KU-03/04. Sequencing and phylogenetic analysis of the HA and NA genes of HPAI isolates (cat and pigeon) showed that the HA and NA genes of the viruses were similar to each other as well as to those of the viruses isolated from tigers, chickens, and humans in Thailand^ref.
Regarding the origin of the tiger virus, feeding the tiger with birds infected with AI virus should be considered one of the possibilities. 83 tigers, aged between 8 months and 2 years, either died or were culled due to AI within 3 days following the onset of clinical signs with severe pulmonary lesions, including 30 put down on Oct 20 to prevent the virus from spreading after they had been fed raw chicken at the private Sri Racha Tigers Zoo, in eastern Thailand 80 km (50 miles) east of Bangkok since 14 Oct 2004. The zoo had been closed since 19 Oct, and about 30 of 441 tigers in the zoo were ill. The zoo was raided and 441 tigers were confiscated, 53 of which tested positive for H₅N₁. 147 out of 441 tigers were loss due to the virus or culling. The at-risk group of tigers was re-treated with oseltamivir, administered twice daily (morning and evening) in a piece of meat for 5 consecutive days (< 60 kg body weight: 75 mg/animal/dose; 60 kg body weight and above: 150 mg/animal/dose). No clinical disease or deaths have been observed in any species in the zoo since 28 Oct 2004. 5 keepers had been put under surveillance after showing flu-like symptoms, but the other 800 workers employed by the zoo and the processing firm had shown no signs of illness. Medical check-ups on 500 zoo employees found no bird-flu infections. The crude attack rate for AI in these zoo tigers is 12.5%, but this may be a minimum estimate, as the report does not indicate whether all tigers in the zoo were fed contaminated feed. Indeed, it may be impossible to know except in the unlikely situation in which the feed source is still available and excellent records were kept. Influenza A virus was isolated from the sick tigers' nasal swabs; A/Tiger/Thailand/CU-T3/04 (HA and NA gene; AY842935-6; PB2 and NS gene; AY907672-3) was initiated from those pretreated with oseltamivir, and A/Tiger/Thailand/CU-T7/04 (hemagglutinin [HA] and neuraminidase [NA] gene; AY866475-6, PB2; AY907671 and NS; AY907674) was isolated from those posttreated. Sequencing and phylogenetic analysis of the HA and NA genes of the H₅N₁ isolates in this outbreak showed that they were similar to each other as well as to those of the virus obtained from the earlier cases identified in 2004. The HA gene contained a glutamine at position 222 (226 in H₃) in HA1 and 4 polybasic amino acid insertions at the cleavage site, which had also been found in other recent H₅N₁ isolates from chicken and tigers. However, no mutation of histidine to tyrosine was seen at position 274 of the NA molecule after oseltamivir treatment^ref.
The suppliers of the potentially contaminated batches of whole or chicken bone carcasses have been accused by the Department of Livestock Development of illegal animal movement in contravention of the Animal Epidemics Act B.E. 2499 (1956) and Revision BE 2542 (1999). They have been questioned by the police. The case fatality rate of 55% indicates either some combination of high doses of virus, highly susceptible tigers and/or a particularly virulent H₅N₁ strain. The deaths of the tigers had no implications for humans, as tigers are not known to host the human influenza virus and thus could not serve as a lethal mixing vessel. While there is some claim that tiger-to-tiger transmission of disease did not occur, the appropriate attack rate information by feeds fed and not fed -- flowing from a well-executed outbreak investigation -- are lacking.  In the absence of such information, conclusions about foodborne spread will be difficult to establish scientifically and therefore remain speculative. This report intimates that tiger-to-tiger transmission is unlikely, but chicken was fed to tigers who remained healthy. The problem is whether the chicken fed to the healthy tigers was contaminated with influenza; chickens are obtained from more than one supplier. In any foodborne outbreak, trace-back to slaughterhouses and production farms is often a record-keeping obstacle that cannot be surmounted. > 5000 Thai and foreign tourists flocked to Sri Racha Tiger Zoo when it unofficially reopened on Nov 19 after a month-long quarantine.
196 local cattle breeds roaming freely in the village started dying 4 Feb 2004 near the mountains of northeastern Kalasin province, 430 km (270 miles) northeast of Bangkok : authorities would be unable to conduct lab tests for bird flu from the cattle's carcasses because the animals had been eaten by villagers or sent to slaughterhouses. Tests will instead be done on the cattle's manure. Other causes could be FMD or hemorrhagic septicemia. The situation should be carefully watched, since after 1st passage through a mammal, transmission to another mammalian species, including humans, may be easier.
On Feb 2006 it was reported that in 2005 large numbers of domestic dogs (160 out of 629) and cats (8 out of 11) in the Suphan Buri district have antibodies against the H₅N₁ strain of avian flu. So far, researchers at Bangkok's Chulalongkorn University have isolated the virus from at least one of the dogs. This unpublished study is the first to look at the prevalence of the virus in dogs or cats in the field — despite anecdotal reports of cat deaths near poultry outbreaks^ref.
The second wave (3 Jul 2004 to 12 Apr 2005) :
• a recurrence of the fatal bird-flu virus killed 1575 birds (layer, broiler, duck, goose, 7 ostriches, native chickens, in ventilated houses located in the same cluster) at an isolated research farm of Agriculture Faculty at Mae Haeh Sub-District, Muang District, Chiangmai Province University : the fatal disease might have been spread from an infected farm nearby where chickens were culled one month ago, or from migratory birds that had stopped at a pond near the farm, clearly demonstrates that the virus is still circulating. Anyway no provincial university in Thailand has facilities at the P3 biocontainment level suitable for conducting experimental work with HPAI virus
• from 3 Jul to 27 Aug 2004 98 outbreaks in 26 provinces : Ayuttaya (7,000 chickens killed and 43 000 stamped out), Chiang Rai (60 non-farm chickens), Sukothai, Utradit (on Sun 11 July), Nakornsawan, Kampangpetch (on Wed 14 Jul among chickens), Uthaitani, and Pitsanuloke (Northern provinces); Patumtani (Bang-Kra-dee subdistrict, Muang district; since Jul 4, in layers), Angthong, Supanburi, Lopburi, Saraburi, Bangkok, and Nontaburi (Central provinces); Cholburi, Chachengsao, Nakornnayok, and Prachinburi (Eastern provinces); NongKhai, KhonKhan (Northeastern provinces); Narathiwat, Songkhla (Southern provinces). AI infection in native chickens in Koke sa lood, Lopburi Province, layer chickens in Wiharndang, Saraburi Province, and ducks in Bang bua tong, Nontaburi Province were confirmed on 23 Aug 2004. Within the 98 areas, 73 areas in 24 provinces have undergone a 21-day surveillance period without additional cases. Total number of poultry destroyed since 3 July is 324 859 and 35 000 quail eggs since 3 Jul 2004. Regulations came into effect to control the illegal use of AI vaccines : users of vaccine can be fined and jailed for up to 3 years. The total number of poultry culled was 228 743 (chickens (200,000 culled), fighting cocks, geese, ducks, layers, broilers, quails), along with the destruction of > 35,000 quail eggs. Suspected cases of HPAI infection were reported, on 16 Sep 2004, in ducks in Supan buri; native chickens in Chaceangsao, Kalasin, Lopburi, and Udornthani; and ducks and native chickens in Sakaew Provinces. An outbreak in broilers was confirmed in Nong nangnual, Uthai thani Province, on 16 Sep 2004, and 14 459 birds were culled. Outbreaks were also reported during Aug 2004 in Narathiwat Province, which is adjacent to the Malaysian State of Kelantan
• a 19-year-old woman from northern Thai Nguyen province 's Phu Luong district was admitted to hospital on Sat 28 Aug 2004
• a 22-year-old woman from northern Thai Nguyen province 's Phu Luong district was admitted to hospital on Sat 28 Aug and died on Fri 27 Aug 2004
• an 18 year old male who lived in Prachinburi Province in the eastern region (3 hours drive from Bangkok) of Thailand, a region which earlier this year experienced confirmed H₅N₁ outbreaks in poultry, raised 30 fighting cocks in his back yard. The chickens started falling ill and died one by one since mid August 2004. He had very close contact to those fighting cocks by carrying and helping to clear up the mucous secretion from the throat of the cock during the fighting game by using his mouth. He developed symptoms of fever, cough and diarrhea on 31 Aug and did not go to the community hospital until 4 Sep when he was admitted. His chest x-ray showed rapid progress of infiltration on the left lung and progressed to ARDS on 7 Sep and died on the morning of 8 Sep
• an 11 year old girl had onset on 2 Sep 2004 and died of bird flu on 8 Sep in the north eastern province of Kamphaeng Phet, lying some 380 km northeast of Bangkok, after a week in hospital. The girl, who lived in the northern province of Kamphaeng Phet, resided with her aunt : both patients 3-4 days earlier destroyed some dead chickens
• her 26-yrs old mother, Pranee Thongchan, had not been in contact with infected animals : she lived near Bangkok but traveled north to provide 16 to 18 hours of unprotected nursing bedside care for her daughter while hospitalized, up to the time of the child's death, and attended her funeral. The mother fell ill upon her return to Bangkok on Sep 11, where she died on Mon 20 Sep : the girl has been confirmed with H₅N₁ infection but she had not been listed as a suspected bird flu case until her mother died. Chances of detecting the H₅N₁ virus in the mother are rather slim as her body has already been injected with formalin. Thai health authorities fear she could be the first case of human to human transmission of infection. Health officials remain hopeful that human-to-human transmission is still inefficient. In the latest case, the mother is understood to have had extensive, close contact with her daughter as she cared for her
• the girl's 32-year-old aunt also provided unprotected nursing care; she had fever on 16 Sep 5 days after the mother first had fever, > 2 weeks after destroying the sick bird, followed by pneumonia 7 days later : this is much longer than flu's incubation period, so she too might have acquired the virus from her relatives rather than the birds. She recovered in Kampaengphet hospital and H₅N₁ infection has been confirmed on Mon 27 Sep. Autopsy tissue from the mother and nasopharyngeal and throat swabs from the aunt were positive for influenza A (H₅N₁) by RT-PCR. No additional chains of transmission were identified, and sequencing of the viral genes identified no change in the receptor-binding site of the hemagglutinin or other key features of the virus. The sequences of all 8 viral gene segments clustered closely with other H₅N₁ sequences from recent avian isolates in Thailand. Disease in the mother and aunt probably resulted from person-to-person transmission of this lethal AI virus during unprotected exposure to the critically ill index patient^ref
• the family cluster also includes the 6-year-old son of the aunt of the initial case : he was hospitalized but is recovering, and samples are being tested
• 9 more people in the province are suspected cases, including a separate 13 year old boy living in Khanu Woralak-saburi, the same district, who also passed away with pneumonia symptoms on Mon Sep 21. The Thai case was a "fluke" in that the mother and daughter lived apart, whereas in families living under the same roof it was impossible to tell whether infected people caught bird flu from chickens or from each other. Suspicions of person-to-person transmission in Hong Kong in 1997, when the H₅N₁ virus first appeared, and in Vietnam in 2004 could not be substantiated for that reason^{ref1, ref2, ref3, ref4, ref5, ref6, ref7}. > 900 000 unpaid Thai volunteers, part of a group set up in 1984 and given some medical training, began work on Friday Oct 1 2004, carrying out house-to-house checks for signs of the disease in both humans and poultry, assigned to oversee some 10 households each. A dog in the southeastern province of Prachinburi, where previous cases had been found in humans and poultry, was confirmed to have been infected with H₅N₁ virus on Sun 3 Oct 2004. A 9-year-old girl from the northern province of Phetchabun developed symptoms on 23 Sep 2004, was admitted to hospital on 27 Sep, and died of severe respiratory disease on Sun 3 Oct : test results on Sun 3 Oct confirmed she has the H₅N₁ strain of AI A virus. Investigation of the case has identified exposure to diseased chickens as the most likely cause of infection. Following the death of chickens in the child's household, she assisted in preparation of the birds for cooking, including the plucking of feathers
• a suspected case in Kampaengphet
• one following probable case in Kampaengphet
• a 14-year-old female, from PaNgue commune, Si Satchanalai district, Sukothai Province, experienced onset of illness on 8 Oct 2004, was hospitalised and died on Oct 19. Chickens at her household died suddenly in late September 2004, but she had no history of direct contact with chickens
• a 7-year-old boy, resident of tambon Matoom, Phrom Phiram district, Phitsanulok province, fell ill after touching dead chickens in a neighborhood area in his village Sat 5 Feb 2005. He was sent to the Phra Buddha Chinarat Hospital a day later suffering from a high fever. He was treated for the fever and quarantined in the hospital's infection-control room, but tested negative for AI. 5 people have been put on the Public Health Ministry's list of suspected AI cases since 1 Jan 2005, but none have been confirmed by laboratory tests.
• a 6-year-old boy from Bangrakam district, Phitsanulok province, has had a record of close physical contact with chickens. On 13 Feb 2005 he is currently under constant medical supervision (total : 18 cases (17 according to WHO statistics), 12 deaths).

Researchers from Thailand and Hong Kong found at autopsy an atypical pattern of infection -- deep in the lungs, away from the tracheal lining where virus could easily be coughed out at others -- may help explain why avian H₅N₁ influenza virus doesn't yet spread easily among people. But the very fact that a paper containing autopsy data from a single case is still desirable to journal editors a year-a-half into the H₅N₁ avian influenza outbreak underscores a problem that has been plaguing the scientific world's pursuit of knowledge about this potentially dangerous strain of avian influenza virus. While at least 54 people have died from H₅N₁ infections since December 2003, autopsies have been performed on fewer than a handful of cases. For cultural and other reasons, body after body has been buried or cremated, robbing pathologists of the precious chance to chart the havoc the virus wreaks on its victims. That's one of the reasons why it's so difficult to understand what the virus does in the body. Did it do more damage on the
intestine? Is the heart affected? Encephalitis: Yes? No? What is the damage in the lung? That's why postmortems are so important. But ... there are
< 5 done, so far. And all in Thailand. Thailand hasn't reported a human case in the most recent wave of infections, which began in December 2004. That means science has no autopsy data with which to try to explain the worrisome changes in infection patterns that have been observed over the last 6 months in Viet Nam, changes which flu experts fear mean the virus is becoming more transmissible and more likely to spark an influenza pandemic. Without information that can only be gathered through autopsies, scientists devising treatment options and potential vaccines are working, if not in the dark, then in a dim light. If we want to test vaccine or antiviral strategies for intervention, we would like to know what the disease looks like in humans. Drugs and vaccines are tested in animals before being administered to people. But without having a clear picture of what the disease does in humans, it's difficult to select the appropriate animal model. Animals used as models must experience a pattern of infection that closely mimics human disease in order for scientists to feel secure that what they are learning might apply to people. Determining which organs the virus is attacking is also crucial from an infection control point of view, because it helps identify possible modes of transmission. In some avian species, massive amounts of the H₅N₁ virus are excreted in feces. Excreted virus isn't a threat with human flu viruses. But if H₅N₁ replicates in the human gastrointestinal tract, patients who experience diarrhea could contaminate their environments in ways health care workers might not expect from a respiratory virus. The autopsy on the Thai boy found viral replication in the intestine. Autopsies could also show whether the virus is being spread through the blood supply to other organs. You want to see whether the cause is in the blood supply and therefore may be a systemic or body-wide problem, or if it's organ-specific. In certain cultures and religions, getting permission from relatives to conduct autopsies is virtually impossible. And in steamy climates like that of Southeast Asia, prompt disposal of corpses is the norm. Even if more people were willing to authorize postmortems, there is another problem : H₅N₁ influenza isn't claiming its victims fast enough. The problem is you have to wait for the people to die, and they're just not dying early enough. They die after several weeks in intensive care, and all the (viral) tracks are gone. Getting people who die from rapid, fulminant disease early to look at when everything's sort of fresh is the trick.
• on Fri 1 Oct H₅N₁ bird flu virus was found in chicken and ducks in the northeastern provinces of Roi Et and Chaiyaphum, the northern province of Uttaradit and in Yala province bordering northern Malaysia. So far, 92 areas in 35 of Thailand's 76 provinces are under bird flu watch, of which 50 areas were confirmed to have been hit by the bird flu virus
• attempted smuggling :
• a Thai man, whose name was not released, was detained briefly on Monday 18 Oct 2004, after customs officials at Brussels International Airport (Zaventem) discovered 2 mountain hawk eagles (Spizaetus nipalensis) hidden in plastic tubes in his hand luggage, which he had carried on flights from Bangkok via Vienna. Since the beginning of 2004, the European Union has strictly prohibited the importation of birds from South-East Asian countries. The birds were destroyed immediately at the quarantined holding zone of the airport, but the man was released on bail. The raptors were taken to the airport customs inspection center (PIF), where they were examined by an official veterinarian of the Federal Agency for Food Chain Safety (AFSCA), which is the competent authority for controlling live animals imports. The 2 birds did not show any clinical signs. In view of the illegal nature of the importation, they were euthanized and transferred to CERVA, the Belgian diagnostic and reference laboratory for AI, for further tests. A veterinarian, who put down the 2 small eagles smuggled from Thailand shortly after they were discovered at Brussels airport last week, presented a bilateral conjunctivitis 3 days after having handled the infected eagle and was admitted to Erasmus Medical College, Rotterdam, but has recovered. He has no other complaints and physical examination was normal. He was requested to remain at home with oseltamivir as prevention. Results from the tear swab were negative for H₅. Unless there is a previous positive test from the veterinarian, there may never be any definitive evidence for an association of his symptoms with the strain reported here. If conjunctivitis was already described with H₇ virus (1997 in the UK and 2003 in The Netherlands), it was not a described symptom of H₅ human infection, even in Hong Kong in 1997. Nevertheless the presentation is similar in both cases. Swabs (2 nasal & 1 throat) from 23 persons (21 customs officers, the Thai  passenger and his brother) were performed on 24 Oct 2004 : one sample from one healthy custom officer was weakly positive for type A. This sample has to be tested again as it could be a false positive for influenza A or a true influenza A virus belonging to another sub-type, probably of human origin. The 1st results on the eagles were obtained on 22 Oct : the 2 birds were found to be positive for HPAI virus  H₅N₁(IVPI = 2.92), with sequence of cleavage site consistent with that of the HPAI strains currently circulating in Thailand (6 basic residues). On receipt of the test results, the Agence Fédérale pour la Sécurité de la Chaîne Alimentaire (AFSCA : Federal Agency for Food Chain Safety) immediately traced all the other consignments of birds that had passed through the airport PIF since 18 Oct. 2 parrots that were being kept at the customs inspection centre as the 2 raptors and 200 parrots in a quarantine centre were also euthanized in order to conduct further tests. In addition, 2 consignments of birds from Africa were controlled at the PIF and placed under official surveillance in quarantine centers in Belgium : 450 birds euthanised birds were taken to the CERVA for further testing (RT-PCR and virus isolation in embryonated eggs). All the RT-PCR tests were negative for the H₅N₁ strain. The other tests are still in progress. In addition, the AFSCA informed the authorities in the Netherlands and Russia that, in the meantime, 6 other consignments of live birds from Africa had already been shipped to quarantine centers in these countries. In view of the fact that the 2 infected birds did not leave accredited quarantine centers, this diagnosis has no effect on the sanitary status of the Belgian poultry population. Health authorities then launched a manhunt, appealing to him to report to police and saying he was at risk of contracting the virus from his contact with the birds. It was not immediately clear whether he had handed himself in or was found by police on Sunday 24 Oct. Authorities detained the man and took him to a hospital in the northern port city of Antwerp : he was undergoing medical tests, but appeared to be in good health. Health authorities stressed there was little chance he could have passed the disease to other people. European and Belgian authorities, however, urged all 128 passengers on the same flight as the birds to contact doctors if they developed flu symptoms in the next 7 days. The man and his birds flew on EVA Airways flight BR0061 from Bangkok to Vienna on 17/18 Oct, arriving in the Austrian capital on 18 Oct at 5:30, then connected with Austrian Airlines flight OS351 to Brussels, where arrived at 8:50. Although the risk of transmission from animals to humans is limited, it cannot be excluded, since the birds traveled in the passenger cabin. Customs and health officials in contact with the birds at Brussels airport have been given medical checks and anti-viral medicines^ref.
• a 34 yo Thai man from Thailand's southern province, was arrested at a police roadblock in Jertih at 7:30 pm of 11 Jan 2005 and was charged in the Sessions Court after he was caught with 120 doves, believed to have been smuggled from Thailand. The birds, packed in boxes, tested positive to the avian flu virus (RT-PCR ?). The court has given orders to destroy all the birds and the man has been remanded for a week beginning today pending hearing of the case.
• hundreds of pigeon carcasses were found at Sri Saliam primary school and nearby Thung Saliam kindergarten in Sukhothai's Thung Saliam district on 5 Nov and H₅N₁ was confirmed on 17 Nov. None of the students showed symptoms
• during October 2004 166 new outbreaks of AI were reported in 99 districts of 29 provinces and involved the destruction of (incomplete figures) 20,442 avians. Laboratory tests on pigs that had died in early October 2004 in the eastern Prachinburi province showed that they were killed not by bird flu, but bacterial infection. Since 3 Jul to 18 Nov, H₅N₁ HPAI infection has been confirmed in 57 provinces and more than 1 million birds have died or been culled in response. As at 9 Nov 2004, 261 locations in 44 provinces were subjected to the 21 day surveillance period imposed by the Department of Livestock Development (DLD), Ministry of Agriculture and Cooperatives. HPAI outbreaks were confirmed in 117 districts in the week of 8 Nov, and 37 in the week of 15 Nov 2004, resulted in culling of 87 385 and 63 378 birds, respectively. In early November, birds were observed falling from the sky in Mae Hong Son. The bodies of the fallen birds were sent to a laboratory for testing on 5 Nov. there were 24 suspected bird flu cases in Thailand in the 2nd half of 2004, according to the government Avian Influenza Operations Centre. 11 of these cases were in the south, 7 in the north, 4 in the north east, and 2 in the central region. All patients were under medical supervision, while the results of laboratory tests were pending. There is another suspected human bird-flu case in the country's northern province of Kamphaeng Phet.
• Ayudhaya province, Lad Bualuang district / 1
• NakhonSawan province, Tha Tako district / 2
• Phichit province, Muang district / 1
• PhitsanuLok province, Bang Krathum district / 5
• PhitsanuLok province, Muang district / 2
• Suphan Buri province, Don Chedi district / 1
• Total / 12
• Description of affected population in the new outbreaks: local poultry, meat-type ducks, laying ducks, laying hens, broilers, fighting cocks.
• Total number of animals in the new outbreaks: species / susceptible / cases / deaths / destroyed / slaughtered
• avi / 3300 / 241 / 241 / 3059 / 0
• a random sampling of 101 migratory and indigenous wild birds in the 4 central provinces of Nakhon Sawan, Lop Buri, Chachoengsao, and Saraburi had shown 10 animals belonging to 6 native species (3 out of 6 pigeon samples collected from Chachengsao province (1), Nakhon Sawan (3) and Lop Buri (2), 2 out of 15 Asian open-bill storks, one little cormorant and a red-collar dove from Nakhon Sawan, one scaly-breasted munia from Saraburi, and a black drongo from Lop Buri), while none of the samples of migratory birds tested positive. As of 9 Dec 2004, the number of areas under watch had dropped from 122 spots in 21 provinces to 71 areas in 19 provinces have reported cases of the virus, with new outbreaks in the southern provinces of Pattani and Narathiwat (Nakon Sri Thammarat)
• unofficial (thus unauthorised and uncontrolled) vaccinations have been carried out by poultry growers in Thailand on an unknown scale, and probably also in other countries in the region. By opting for geographically-restricted vaccination trials, the Thai authorities might be attempting to regionalise the disease. This means that if accepted by the importing countries, Thailand might be allowed to continue exporting from disease-free, non-vaccinating areas. The decision falls in line with the recent views of OIE/WHO/FAO, which published updated recommendations at the end of Nov 2004. The document included the following statement: "Such control needs to consider all suitable measures ranging from the safe and swift elimination of affected poultry, through strict biosecurity, movement and market control and if relevant, to vaccination and its close monitoring".
• a study examined the pathobiology and epidemiology of H₅N₁ influenza virus in the 4 systems of duck raising used in Thailand in 2004. No influenza viruses were detected in ducks raised in "closed" houses with high biosecurity. However, H₅N₁ influenza virus was prevalent among ducks raised in "open" houses, free-ranging (grazing) ducks, and backyard ducks^ref.
• new outbreaks of HPAI in 13 provinces:
• in the northeastern province of Nong Khai, along the Laos border, the virus was found in the districts of Thabor and Sri Chiang Mai, where 208 chickens had died of the disease. Another 73 of the birds were culled to prevent the disease from spreading
• in the eastern province of Rayong, Klaeng (Klang) district since Jan 7 week (in follow-up report No. 40 of 14 Jan 2005) : a flock of 40 native chickens and 10 cases were recorded; the remaining 30 birds were destroyed
• in the central province of Chachoengsao doves died of bird flu
• in the central province of Lop Buri a Zebra dove died of bird flu
• in the central province of Nakhon Sawan : 1 outbreak during the 1st week of 2005. Another outbreak was confirmed 28 Jan 2005 in Krok Phra district, where 37 chickens died. Between 18 Jan and 3 Feb, 496 open-billed storks had been found dead at the Bung Boraphet wildlife reservoir (73 of them on 3 Feb 2005 alone), Thailand's largest freshwater swamp. The infected storks probably caught the virus from ducks while they fed elsewhere before flying back to their nests in the centre of the wildlife refuge. Some concerned parties demanded a cull, arguing the storks brought the disease with them to Thailand. But wildlife officials have argued the birds' country of origin, Bangladesh, has reported no bird flu cases. The officials said the storks probably caught the virus during their stay in Thailand
• in the central province of Phitsanulok : 6 outbreaks during the 1st week of 2005, where 50 locally bred chickens were confirmed to have the disease on 17 Jan. 1 in  Bang Krathum district, the other one in Muang district (in follow-up report No 41 dated 20 Jan 2005). Other outbreaks in the districts of Bang Krathum, Phrom Phiram (worst hit, with H₅N₁ virus detected in 8 different localities and > 1000 chickens culled), Wang Thong, and Wat Bot.
• in the central province of Sukhothai doves died of bird flu
• in the central province of Uthai Thani, where more than 400 pigeons were culled and doves died of bird flu.
• Uttaradit province : an outbreak was confirmed on 24 Jan 2005 in the Pichai district of Uttaradit, where 78 chickens died of the flu and 22 others were culled to prevent the disease from spreading
• in Pichit province, about 350 kilometers (215 miles) north of Bangkok, where 20 chickens died of the disease and 27 more were culled.
• Nakhon Pathom province
• in Suphan Buri province, avian influenza was confirmed in chickens in Song Phi Nong and Muang districts. Suphan Buri authorities have culled almost 3000 chickens infected with the virus in the province's Song Phi Nong district. Early in February 2005, 900 chickens in the district's tambon Sri Samran, and 2000 in tambon Bang Plub, were culled, after tests showed they were infected with the virus
• in Phichit province, it was confirmed in the Sak Lek subdistrict
Phitsanulok and Rayong were under the 21-day bird-flu watch but other provinces had not reported any ill or dead poultry. Chicken-raisers are warned to apply early next month for permission to transport chickens before selling them for Chinese New Year celebrations. If they try to move them without the necessary documents, farmers will be subject to a 2-year jail term for breaking the Animal Quarantine Act. On 10 Feb 2005 Thailand planned to cull about 2.7 million young free-range ducks in an effort to prevent further bird flu outbreaks and eradicate the virus from the kingdom, a decision backed by the belief that ducks are more resistant than other fowls and could carry the disease longer without showing any symptoms of infection, and that the nomadic nature of free-range duck farming may have exacerbated the spread of the disease. Trying to get rid of the virus, the Thai government has earlier moved > 1 million adult ducks to closed farms or slaughter houses, confined 5.5 million ducks to certain areas, and destroyed 4 million duck eggs. The bird flu committee would ask a 5-billion-baht (about 125 million US dollars) mortgage reimbursement fund for frozen chickens and ducks and the culling. Last known outbreak: 10-17 Mar 2005. A total of 50 birds have died or been culled in Ban Dan Lan Hoi district, Sukhothai Province. Thailand hasn't identified a human case of H₅N₁ infection since the death last October 2004 of a 14-year-old girl in Sukhothai province, but poultry outbreaks had continued. Yesterday marked the end of a 3-week surveillance period at a farm in Lop Buri, the last place to have reported an H₅N₁ outbreak : this is the 1st time Thailand has been free of avian flu since the disease re-emerged in July 2004. Since the 1st ("emergency") report from Thailand on the diagnosis of HPAI, type H₅N₁, on 23 Jan 2004, the said country has meticulously sent follow-up reports to the OIE, almost on a weekly basis. The last report pertaining to new outbreaks, namely follow-up report No 51, was sent on 12 Apr 2005. It referred to 3 new outbreaks, of  which 2 were in Suphan Buri province and 1 in Lop Buri province. The later reports, 52 and 53 (29 Apr and 6 May 2005, respectively), announced the absence of new cases. OIE's last update (6 May 2005) of the HPAI H₅N₁ panzootic, which initially begun in Dec 2003, including the number of accumulated outbreaks in each country, provides the following figures: Cambodia (15), China (50), Hong Kong (4), Indonesia (207), Japan (5), S.Korea (19), Laos (1), Malaysia (10), Thailand (1092) and Viet Nam (1837). Of these, 3 countries have already sent their final reports to the OIE, in which they notified their regained freedom from HPAI: Japan (on 13 Jul 2004), S. Korea (on 24 Sep 2004) and Malaysia (on 4 Jan 2005). This was done in line with article 2.7.12.2. of OIE's Terrestrial Animal Health Code. According to the said article, a country may be considered free from HPAI when it has been shown that HPAI has not been present for at least the past 3 years; or 6 months after the slaughter of the last affected animal for countries in which a stamping-out policy is practiced with or without vaccination against HPAI. The above 3 countries applied stamping-out and refrained from vaccinating. Thailand has adopted the same policy, and will be able to declare its HPAI-free status under the said time-table
The last outbreak was on 12 Apr 2005 at Lop Buri Province. The National Strategic Plan for Avian Influenza Control Thailand was approved by the
Thai Cabinet on 25 Jan 2005 and has been operational. The plan includes: development of a disease-free poultry management system; analysis of the
situation and preparation for use of vaccines for prevention of the disease in poultry; disease surveillance and response during outbreaks; knowledge generation and management; capacity building of organizations and manpower; improvement of understanding and participation of the civil society and private sectors; and development of sustainable integrated management systems and mechanisms. Chicken exports this year from Thailand are expected to reach 300 000 tonnes due to the easing of the bird flu outbreak, according to the Thai Broiler Processing Exporters Association. The poultry meat export from Thailand before HPAI crisis was 624 000 tonnes (2003, FAOSTAT). The shipment will be mainly cooked products, since raw poultry meat has been banned in big export markets such as Japan and Europe.
During the 2nd nationwide active surveillance campaign, being conducted 1-31 July 2005, 9 bird flu outbreaks were detected since 5 Jul in Suphanburi province, 100 km (60 miles) north of Bangkok :
• 5 outbreaks occurred in Sam Chuk district according to OIE follow-up report No. 60, and > 450 fowl have been destroyed. Thailand had been carefully monitoring for signs of the disease in pigs but had not found any instances of the virus. Before the detection of the fresh bird flu case, the Agriculture Ministry had planned to declare the country "bird flu-free" on Tue 12 Jul 2005, 90 days after the last recorded bird flu case in Lopburi province. The discoveries reinforced warnings by international health bodies about how difficult it will be to eliminate the H₅N₁ virus now it has become endemic in parts of Asia. Infected fowl are living longer due to increasing immunity, meaning it was less likely that unusual deaths would alert farmers to the possibility of infection^ref.
• 4 outbreaks occurred in Muang district : > 1000 layer chickens there died and about 15 000 have been culled. ubdistrict/Start/Species/Susceptible/cases/deaths/destroyed/slaughtered
• Tah Rahad/ 13 Jul 2005/ native free-ranging chicken/40 /10 /10 /30 /-
• Suan Tang/13 Jul  2005/ broiler/16 000 / 1638 / 1638 / 14 362/-
• Rai Rot/ 13 Jul 2005 / native free-ranging chicken / 114 / 45 / 45 /69 /-
• Sala Khao/ 5 Jul 2005 (confirmed 14 Jul 2005) / quail / 122 222 / 14 880 /14 880 /107 /120 /-
The third wave : Thailand has been meticulously sending to the OIE detailed weekly disease information updates on avian influenza since 12 Mar 2004. The disease was reportedly absent between 12 Apr 2005 and 5 Jul 2005, when new cases were reported from native poultry and fighting cocks in villages where biosecurity is minimal. These findings resulted from a nationwide active surveillance campaign conducted since 1 Jul 2005. The purpose of this surveillance is to evaluate the present status of highly pathogenic avian influenza after the 2nd wave of outbreaks between 3 Jul 2004 and 12 Apr 2005. As a result of this 2-month campaign, 64 new outbreaks have been confirmed in 8 provinces in the Central Poultry Zone of Thailand (the country has been divided into 5 poultry zones: Northern (9 provinces), Northeastern (19 provinces), Eastern (8 provinces), Central (25 provinces), and the Southern (15 provinces), for the effective movement control and farming management) :
• affected province/ No. of outbreaks
• Ayudhaya/ 1
• Chainat/ 1 : on Aug 4 2005 bird flu virus was found in the samples of free-range ducks from the central province of Chai Nat : the department ordered the culling of more than 1,700 ducks and announced an inensified 21-day surveillance in the area
• Kampaengphet/ 25
• KanchanaBuri /6
• NakhonPathom /4 : a quail farm for egg production
• NonthaBuri /2
• Saraburi /5
• SuphanBuri /20
• affected population/ No. of outbreaks
• native poultry /47
• quail /6
• broilers /4
• fighting cocks /4
• laying ducks /2
• laying hens /1
H₅N₁ has spread to more than half the country, with 39 provinces reporting confirmed or suspected cases of fresh bird-flu infections
All cases involved either free-range poultry or poultry raised in farms with traditional husbandry practices with poor sanitation and insufficient biosecurity, notably in the 3 outbreaks involving quail. The outbreaks, together with another in Ban Sabmanao in Klongthalung district, were controlled
Further details on the said surveillance campaign, as well as the last follow-up report (No 66) notifying data on 6 outbreaks which had started between 23-30 Aug 2005 (LakChai, LadBuaLuang, Ayudhaya province; TungSai, SaiThongWatana, 2 in WangChaOane, BungSamakkee, and 2 in WangSai, KlongKlung, all 5 in Kampaengphet province), are available^ref. An administrative map of Thailand is available^ref. Thailand seems to have successfully eradicated the disease in commercial flocks, without vaccination, in an effort to restore exports (applying the zoning/compartmentalisation principles, this might be achieved). The struggle to control the continued infection in small holdings has to be continued. The data provided in the Office International des Epizooties (OIE) report
of 30 Aug 2005 submitted by Thailand seem to suggest the existence -- or appearance -- of possible resistance to H₅N₁ in one or more native Thai chicken breeds. The OIE report indicates that in one reported outbreak none of the 10 infected chickens died, and in another only 5 of 15 infected chickens died^ref. If the phenomenon is widespread, it seems that this could indicate that native chicken flocks as well as domestic ducks are serving as reservoirs for H₅N₁ virus in SE Asia.
18 out of 11 705 samples collected from wild birds (including tree sparrow, pigeons, and mynas) nationwide between June and 7 Oct 2005 had been infected with the H₅N₁ virus : most positive cases had been collected from infection-prone provinces, including Ratchaburi and Kanchanaburi : the laboratory findings have deepened fears of a new outbreak of avian influenza at Thai poultry farms because the Eurasian tree sparrow (some specimens of which were found to be infected) is a very common species in the country. Sumeth Chailertwanitchkul, Nakhon Sawan's province largest swamp, Beung Borapetch, where migratory birds from Siberia normally come to winter was disinfected on 17 Oct 2005. 2 outbreaks of avian influenza in Yang Talat and Huai Mek districts in the northeastern province of Kalasin were confirmed on Tue 25 Oct 2005 and Thu 27 Oct 2005, the 1st case outside the Central region's poultry zone since the 3rd wave of infections in July 2005 : 18 fighting cocks (which might have caught the deadly disease from those in the infected central region) have died or were culled. 34 villagers from the 2 districts, including a 4-month-old baby, have been put under close observation after they developed flu-like symptoms. 4 more tambons [the 3rd administrative subdivision level, below district (amphoe) and province (changwat)] in Kalasin have been put under observation pending lab tests for bird flu outbreaks. On 2 Nov laboratory results confirmed the virus in chickens and pigeons in the central province of Ang Thong. There were around one million fighting cocks in Thailand, 300 000 of them involved in fights regularly, but only 40 000 had been registered and issued with a "passport," which must be shown to officials when they are moved. Owners often hide their prized fighters, as the government pays only 75% of the market rate for ordinary chickens culled, no matter what their attributes, and nothing if they did not report suspicious deaths.
• a 50-year-old woman from Bangkok developed symptoms on 26 Oct 2005 and was admitted to a Bangkok hospital on Sat 29 Oct 2005 after telling her doctor she had visited her husband (Visan Chaowangyen) in Nonthaburi Province, north of Bangkok (one of 6 provinces hit by a fresh rash of bird flu outbreaks), on 23 Oct, helping her husband clean up a farm where chicken were culled after laboratory tests showed they had the virus : later it emerged that she took AI from the environment and was the 8th person to contract the virus without touching a dead chicken (6 of those were children who might have caught the virus while playing near infected chicken feces or fluids). On Mon 31 Oct 2005 all 3 lab AI tests showed positive results while she improved. Field investigations have not found any indications of respiratory illness in close contacts of the patient. The husband raised about 30 fighting cocks and bantams in his backyard. When some of them died, he decided to cull the rest because he suspected that they might have been infected with the avian-flu virus. He said he did not report the deaths to authorities as required because he thought culling the infected poultry and burying them properly was enough. He said that was aware that he could have contracted the virus while burying the dead poultry, so he wrapped his hands in plastic bags before touching the dead animals. Although he was in good health, doctors prescribed a 5-day 75 mg bid oseltamivir course for him to take as a preventive measure. The husband was away when his wife went to the Nonthaburi house to visit him : after visiting the house, the woman became ill, tired and found it difficult to breath. She later went to see doctors at Siriraj Hospital because she thought she might have avian influenza. Dr. Kumnuan went to the house in Nonthaburi and said it was very likely that the woman contracted the virus either through exposure to infected feces around the house or from eating fruit that she had picked up off the ground. There were stains of chicken feces on a makeshift wooden stretcher that she sat on while she waited for her husband. Next to the stretcher was a small pond of filthy water containing chicken feces. The woman admitted to eating a piece of fruit that fell from the ground after cleaning it with the dirty water.
• a 14-year-old boy from Phichit was admitted as a suspected bird flu patient after becoming ill. The boy had direct contact with dead chickens. The results of a laboratory test are expected in 3-5days^ref
• a 4-year-old girl from Phichit on 1 Nov 2005 tested positive to the H₃N₂ virus of human influenza, not H₅N₁.
• a 48-year-old man (farmer named Bang-orn Benpad) in Panuamthuan (Phanom Thuan) district of Kanchanaburi province (150 km (94 miles) west of Bangkok), which has recently reported fresh outbreaks of the deadly avian influenza strain in poultry around 100 km (60 miles) west of the capital, Bangkok, developed symptoms on 13 Oct 2005, was hospitalized on 17 Oct 2005, and died on Wed 19 Oct 2005. The 1st lab results came out negative (likely because he was treated with oseltamivir), but new tests confirmed that he was positive. The guy was infected with bird flu because he took a sick chicken, slaughtered it and then ate it. The man's 7-year-old son (Ronnarit Benpad), who had a history of contact with chickens, developed respiratory symptoms on 16 Oct 2005 and tested positive on Oct 21. He had assisted his father with defeathering of the diseased birds : he was treated with oseltamivir early in his illness, recovered his appetite and his fever resolved. The latest case was the 13th fatality from avian influenza in Thailand since the disease first appeared in 2003. The last previous human death was recorded in October 2004. Some 21 of the country's 76 provinces are currently under quarantine or under close watch for the H₅N₁ virus. On Oct 25 2005 3 others in Kanchanaburi were on a list of people suspected of catching bird.
• Kanchanaburi province reported 5 suspected cases of bird flu. All the patients have been given oseltamivir^ref
• a 4-years-old girl from tambon Tha Makham of Muang district, Kanchanaburi, was added on Oct 24 to the list of suspected bird flu infections. The girl´s family raised lovebirds and > 20 of the birds had died from unknown causes^ref.
• Thammanoon Kanluang, 10, a resident of tambon Don Jedi in Phanom Thuan district, was given oseltamivir^ref
• Sam-arn Huohern, 48 (49?^ref), of tambon Pangkru in Phanom Thuan district, was given oseltamivir^ref.
• a 4-year-old boy in Phanom Thuan tested negative for H₅N₁^ref
• a 39-year-old farm worker (Thongpon Klompanya) was admitted to Nakhon Pathom Provincial Hospital on Sun Oct 23 after developing a high fever and he was placed under close watch for bird flu. 5 ducks have died mysteriously on the farm in tambon Prong Madua of Muang district, since Thu Oct 20. The farm belongs to Chalerm Nimpijarn, 70, of Khlong San district, Bangkok. He had 31 bantams, 11 geese, 2 peacocks, all fully grown, and 11 Muscovy ducks there. Mr Chalerm told health and livestock officials yesterday that a pigeon had been found dead in his backyard last week. Then 3 ducks died on Thu Oct 20. He suspected bird flu killed them so he, his driver Prinya Sridaoruang, 35, and Mr Thongpon buried the ducks immediately on the property. Mr Chalerm said he and his driver developed high fevers after returning to his house in Bangkok. Both men recovered fully after treatment (oseltamivir?) at a private hospital. He learned that 2 more of his Muscovy ducks died on Oct 24. Mr Thongpon´s wife, Da, and son, Sakhon, were also sent to the hospital for checks. They had no symptoms but received precautionary treatment (oseltamivir ?). Mrs Da said her family had moved from Si Sa Ket province and lived at the farmhouse for 11 years. She did not think she and her son were infected as they had no contact with the birds. Provincial livestock official Theerapong Visalkitti said that the dead ducks had been sent for tests in Ratchaburi while the farmhouse and its vicinity had been sprayed with disinfectant. Dr Pinij Hiranchote, director of the Nakhon Pathom Provincial Hospital, said Mr Thongpon´s temperature was now lower. He was being kept in isolation and his family could see him only via a television monitor. In Kanchanaburi, 2 more chicken farms in villages in Phanom Thuan an and Tha Maka districts were found to be infected with bird flu. Jatuporn Khamchuen, Phanom Thuan district livestock chief, said samples from culled chickens from one of the 39 villages in the district were found to be infected. There were about 300 chickens at the Bang Nongkae farm, owned by Mian Theppawong. All would be destroyed. Since Oct 11, a total of 20,008 chickens on farms in Phanom Thuan district had been culled, he said. Yingyos Chusomphop, acting chief of the Kanchanaburi livestock office, said chickens from another farm in tambon Phra Thaen in Tha Maka district were found to be infected. They were mainly native chickens. All would be killed. The farm is owned by Mrs Toi Huayhongthong. Mr.Thongpon tested negative for H₅N₁^ref
• Sunee Taokham, 49, from Lampang, was removed from the list of suspected bird flu patients^ref.
• an 18-month-old boy became ill soon after the death of 3 fighting cocks and a chicken kept in his household in the Bangkok suburb of Minburi, developed symptoms on 1 Nov 2005, was admitted to hospital on 5 Nov, and tested positive for H₅N₁ on Nov 11, but he was already well on the way to recovery. The boy's 65-year-old grandmother also had symptoms, but turned out to have ordinary human flu
• a 5-year-old boy from the central province of Nakhonnayok (Nakhon Nayok ?, about 70 km (45 miles) northeast of the capital of Bangkok) developed high fever, stomach pain and vomiting on 25 Nov 2005. 2 days after that he was taken to 2 private clinics that mistook his symptoms for something else, and finally moved on 5 Dec to HRH Princess Maha Chakri Sirindhorn Medical Centre in Nakhon Nayok's Ongkharak district, where, despite treatment with oseltamivir, died on 7 Dec 2005 and tested positive for H₅N₁ on Dec 9 2005. Early results suggest that the child touched some chickens raised by a relative, 4 out of 10 died : anyway the Livestock Development Department found no signs of the virus in the poultry near the victim's house. There were many pigeons around the boy's house and H₅N₁ might have been present in the birds' faeces. As standard procedure, 14 people, including 4 family members who had associated with the boy, were put under observation for 10 days and given a preventive dose of oseltamivir, and 23 hospital staff involved with the care and treatment of the boy were put under a similar monitoring routine. All remain healthy to date^ref. None of the blood samples tested positive. Only the parents, especially the mother, were considered potentially high-risk cases. She had been closely nursing the boy and sometimes kissed the child's cheeks.
Nonthaburi authorities on 26 Oct 2005 culled 3,500 chickens at a farm in Bang Bua Thong district. The first death in the farm of Prachuab Chanchaeng was reported on Oct 24, after which almost 200 chickens per day had died^ref. Nearly 200 ducks died on Wed Oct 17 in tambon Nikhom Pattana in Bang Rakam district of Phitsanulok. A total of 3,442 fowls from 239 houses were culled in the village the minister visited and 176 local people who had been in contact with the birds will be put under close watch until Nov 1. There were also concerns about 500 flocks of free-range ducks and 200,000 fighting cocks whose owners were reportedly being uncooperative^ref.
In February 2006, the Department of Livestock Development conducted the first biannual HPAI active surveillance. During the month, 57 461 cloacal swab samples were collected for virus isolation. To date, no new positive case has been reported in Thailand
• Japan : strain similar to that in South Korea

• 6,000 chickens died in late Dec 2003 (first official notification 13 Jan 2004) at a farm in Yamaguchi prefecture in Honshu, in the country's first bout of AI since 1925. No further spread to other farms has been detected. The veterinary authorities have banned poultry trading among farms within 30 km (18 miles) of a farm and all 34 600 chickens at the infected farm had either died or been destroyed by 20 Jan 2004. The output of Japan's chicken industry in 2001 was 670 billion yen, around 0.1% of the country's gross domestic product that year. The Japanese government has decided to import 3.2 million doses of avian flu vaccines from Mexico (an inactivated, oil-emulsion H₅N₂ vaccine) and stockpile them paying 27 million yen (USD 26 000). The 4 biggest exporter of chickens to Japan are Thailand, China, Brazil, and USA
• another small outbreak in the town of Kokonoe in Oita Prefecture (on the southern island of Kyushu, across a narrow body of water from Yamaguchi) was confirmed on Feb 18 after a private breeder reported to the town hall that 7 of 13 Japanese bantam roosters (also known as capon chickens or Chabo; kept as pets) he raised at his home (together with 1 duck) had died since Feb 14 : 2 of 7 bantams were confirmed
• about 67 000 out of 198 000 chickens have died since Feb 18 to 28 at the Asada Nosan's Funai Nojo chicken farm in the town of Tamba, Kyoto Prefecture : the farm, however, failed to report to the authorities and about 160 000 eggs per day were shipped to 5 prefectures. 9900 live chickens were shipped to a processing plant in the western prefecture of Hyogo (after > 1000 birds died at the Tamba farm on 20 Feb 2004) and 15 000 live chickens to a meat packing firm in the town of Yachiyo in Aichi prefecture on Feb 25-26. Local authorities inspected the farm 27 Feb, based on an anonymous tip. Of the 12 kg trans-shipped to numerous sites in Osaka, 9.3 kg were recovered. 8.4 kg of chicken bones and meat for soup that came from the Hyogo processor were processed into soup stock and sold to a restaurant in Osaka, Japan's second-largest urban area, but only 2.7 kg were sold to consumers at 2 stores. This is a remarkable example of product tracing within 48 hours and an indication of the amount of concern for food safety that exists in the nation : Japan's efforts to prevent HPAI-infected or suspected poultry products from reaching the retail markets are motivated by the fact that raw eggs are widely consumed in Japan; and in Sashimi cooking, raw chicken is often used. Animals taken to slaughterhouse/meat processing plants such as the affected one in Hyogo Prefecture cannot be processed instantly. Newly arrived animals tend to be held with others for a short period of time. A spokesman for the plant in Hyogo Prefecture indicated that all the meat from the 7000 birds received from the farm in Tamba was in frozen storage, and would be destroyed so it would never reach consumers. But the chickens were alive when they arrived, and presumably were able to infect other birds at the site. The live birds at the site tested positive for AI. On March 7 the 67-year-old farm owner Hajimu Asada and his 64-year-old wife Chisako committed suicide and apologised for having caused a great deal of inconvenience to society. Hideaki Asada, 41, president of Asada Nosan Co., and 2 farm officials have been arrested on suspicion of failing to report the chicken deaths in violation of a law to prevent infectious diseases among livestock and poultry : he received 1-year prison term, suspended for 3 years, in August in a Kyoto District Court ruling for failing to report the bird flu outbreak at the farm to authorities. 2 crows among 4 found dead at the infected Asada Nosan Funai Farm (2) and within the movement control area in the nearby township of Sonobe (2; 8-9 km away) were confirmed to be infected with H₅N₁ on Mar 8 : ministry officials are investigating the contagion route at the Asada Nosan Funai Nojo farm in Tanba and the neighboring town of Sonobe. One more in Ibaraki city (a distance of 30 km from Tanba, Osaka prefecture (state)) also tested positive for the disease and a 6th crow was found in the town of Tamba on Mar 13. It is the first time in Japan that wild birds, other than caged poultry, have been confirmed with AI : once a crow contracts the flu, it dies off quickly and its radius of movement is also limited, limiting the possibility of spreading the virus over a wide area. It is most imperative to prevent wild birds from entering poultry farms. 5 people (4 workers and 1 firefighter) out of a group of about 60 made up of mostly Kyoto Prefectural Government employees involved in the clean-up at the Asano Nosan farm all made complete recoveries after being affected by minor ailments : one farm worker, who exhibited seroconversion, had a sore throat for several days just after participating in the operation. However, this person did not develop fever or other systemic symptoms.  4 other people also failed to show systemic flu-like symptoms such as fever. Micro-neutralizing assays showed a significant increase of neutralizing antibody titers (> 1:10) against the influenza A(H₅N₁) Kyoto strain (A/Chicken/Kyoto/3/2004), suggesting their bodies had adjust to fight off the disease. All clean-up workers took oseltamivir phosphate, wore protective clothing and surgical masks. Neither the virus nor its genes were detected among the 5. Some 240,000 chickens and 20 million eggs were disposed of at the farm and another nearby farm to prevent the infection from spreading.
• on Mar 5 AI was found in chickens at the family-run Takada farm, about 5 km  north of Asada Nosan's Funai, in the town of Tamba, where > 130 000 birds perished last week in a flu outbreak, but in the latest case had no contact with birds from the former outbreak.
• on Mar 2 a farm in Shimane prefecture, about 720 kilometres west of Tokyo
• on Mar 11 at a slaughterhouse in Kitakyushu, Fukuoka Prefecture, 126 among 930 chickens were found dead overnight. Initial tests on 10 animals were all negative and birds may have died of heat stroke
• on Mar 14 6 dead bantam chickens were found on a riverbank of the Sakai River in Shitara, Aichi Prefecture, along with 5 live ones, by a man who came to fish in the area
• 3 crows found dead in Kameoka city (Kyoto prefecture), and one of them found positive to H₅N₁ virus
• Japan will have spent 104.8 million yen (USD 951 427) by 31 Mar 2004 on emergency measures to eradicate AI
• North Korea : on Jan 25 the Rescue the North Korean People's Urgent Action Network (RENK) reported that a woman in Pyongyang was infected with bird flu in Dec 2005, after chickens carrying the disease were found, and was admitted to a Red Cross hospital. Scientists from a group representing pro-Pyongyang Koreans living in Japan (the Association of Chosun People in Japan) went to North Korea in Sep 2005 carrying 10 packs of oseltamivir and make checks : however members of the group could not verify whether the woman had been infected with the virulent H₅N₁ strain of avian influenza or a less virulent strain. There have been outbreaks of bird flu in rural areas of North Korea since September 2005 and outbreaks in 3 areas of Pyongyang in December 2005. An outbreak of bird flu that infected humans could be devastating in North Korea, where poultry is an important source of meat for its 23 million people When North Korean leader Kim Jong-Il met Chinese President Hu Jintao during his visit to China earlier in January 2006, he could have asked for Beijing's help in fighting bird flu. Kim reportedly visited a Beijing hospital during the secrecy-shrouded 9-day visit. The Sankei newspaper said it was possible Kim was tested for bird flu at Beijing's No. 301 Hospital of the Chinese People's Liberation Army^ref. The Ministry of Agriculture ruled out all these kinds of rumors, and there is no outbreak and no human cases^ref
• Cambodia^{ref1, ref2, ref3}, which is still recovering still recovering from 3 decades of civil war and the Khmer Rouge, under whose radical back-to-the-land rule an estimated 1.7 million people were killed, or died of starvation and disease : the 1st case of H₅N₁ was observed on 15 Dec 2003 at the Tamao Wildlife Rescue Centre. The 1st case in poultry took place on 24 Dec in a semi-commercial layer flock in Phnom Penh. This was the 1st case reported to the Department of Animal Health and Production (DAHP). Investigation took place on the same day, and the result was reported to the OIE. From 1 Jan to 29 Apr 2004, a total of 91 reports of avian mortality were reported to DAHP, of which 33 were investigated and 12 were confirmed as H₅N₁⁺. Currently there are 3 task forces (TF) in the government to handle various measures: TF-1 (Surveillance, Investigation & Diagnosis); TF-2 (Communication and Mass Media) and TF-3 (Outbreak Control Measures). Stamping out is usually instituted on suspicion of HPAI on commercial/semi-commercial operations, but requires owner consent. In cases involving village chickens, culling of chickens usually takes place at the infected location. The Government enforced a Prakas (decree) on 16 Jan that bans cross-border movements of poultry and poultry products. This may have led a dramatically reduction in external infection pressure. The Prakas also prohibits movement of live poultry into or out of the protection zone (3 km surrounding the affected area), but only after official confirmation of the outbreak -- often a lag of 2-3 weeks from laboratory confirmation. Due to the movement control, some commercial farms in the protection zone decided to sell out all poultry in late January 2004, because they could not afford the cost for keeping birds. There is a common practice of throwing out viscera to be scavenged by free-ranging chickens in villages, and this was a likely factor to virus re-circulation. Poor biosecurity practices appear to have contributed significantly to the spread of the disease. There is a need to start active surveillance with commercial poultry operation providing chicks and feed to many operations around Phnom Penh, and 3-4 km protection zone would follow in its early stages. Laboratory competency must be assured when conducting IFAT and HI testing, as these will be used widely during all surveillance phases. Pathogenicity testing and detailed sequencing work has not yet been carried out on the Cambodian H₅N₁ isolates. Detailed analyses should be conducted in collaboration with OIE/FAO/WHO reference laboratories. Chickens (commercial broilers, layers, and village chickens) are typical of the HPAI clinical forms; ranging from peracute (sudden death with no clinical signs) to acute (2-3 days period until death) manifestations, predominantly seen in younger birds. Lachrymal and nasal discharges, periorbital edema or generally edematous heads, deep red or cyanotic wattles and combs, diarrhea and panting was evident in birds surviving beyond 2-3 days. Soft-shelled eggs characterize affected layer flocks. Mortality can approach 100% in 7-week old birds on an affected layer enterprise. Morbidity and mortality in older birds is more difficult to assess, as owners of commercial enterprises often sold their poultry soon after suspicion of the disease. In a village setting, with a range of ages and low bird density, mortality varied between 50 and 90% at an individual household level. Ducks demonstrated a 2-3 day disease course with clinical signs including lethargy, inability to walk, flaccid necks, and yellow diarrhea. Overall morbidity reached 10% in Black ducks and 20% in White ducks. White ducks appeared to have increased susceptibility with respect to fatality rates approaching 40% in affected individuals. H₅N₁ was also isolated in 2 outbreaks involving non-poultry avian species. A large variety of captive birds as well as free-flying crows were affected in the outbreak at Tamao Zoo, Kandal province. The disease appeared first in raptors such as grey-headed fish eagle, serpent eagles, hawk eagles, spotted wood owls, brown fish owl, spot-bellied eagle owl, and buffy fish owls in the first 2-3 days. The raptors were fed chicken meat or carcasses obtained from the Kandal Market in central Phnom Penh. Consideration must be given to the oral point of entry or respiratory if the contaminated carcass was soiled with affected bird feces. The live poultry market located approximately 30-40 m away from where the serpent eagle's enclosure is another possibility. Herons, egrets and cranes were subsequently affected, suggesting respiratory transmission or mediated through free or wild birds such as crows, which frequent the aviary areas. Psittacines were affected in a further outbreak, although only 2 recent introductions died in an aviary group of 30. A total of 86 birds died and 261 birds remained clinically unaffected. Clinical signs, primarily lethargy and inappetence, were also evident in zoo cats (tiger, leopard, etc. all have recovered). Despite officials initially said the deaths of 4.7 million chickens since November in 3 farms in the outskirts of Phnom Penh had been caused by exotic Newcastle disease, tests conducted by the Pasteur Institute in Paris confirmed on 23 Jan 2004 (first official notification 24 Jan 2004) that 40% have died from avian flu and 60% from Newcastle disease. The poultry sector in Cambodia is relatively small. With customers shying away from chicken for fear of catching the deadly flu virus that has killed millions of birds and at least 20 people, rat butchers been selling more than 200 kg (440 lb) of rodent meat (fried, grilled or roasted with garlic and vegetables) every morning -- twice the normal turnover, fetching around 40 cents a kg in far-flung corners of the jungle-clad and impoverished nation. It is not the only ingredient to be found scuttling on the rural Cambodian menu : spiders, water beetles, crickets, snakes, frogs and ants are all choice treats, with local tradition saying they were first eaten by starving peasants during the Khmer Rouge genocide in the 1970s.
• a Cambodian woman in the Takeo province who died in a Vietnamese hospital didn't have the virus
• a 27-year-old man also in Takeo who worked at a site where animals tested positive for bird flu showed symptoms on Feb 18
5 fowl -- a crow, 2 eagles, a parakeet, and an owl -- among 59 wild birds that mysteriously dropped dead at the Phnom Tamao zoo, 45 km south of Phnom Penh, during Jan 2004 were found to be infected with flu. A dead heron from the zoo had earlier tested positive for the H₅N₁ strain. 2 official notifications on HPAI in Cambodia have been received by the OIE so far. The first one was received on 24 Jan 2004, reporting one outbreak in a layer flock of 7000 chickens, of which 3300 died (though "stamping out" was mentioned, the report indicates "0" as to the number of destroyed or slaughtered animals). On 17 Mar 2004, Dr Sorn San, Chief of National Animal Health and Production Investigation Center, Phnom Penh, informed the OIE about 9 additional outbreaks (2 in the capital, 3 to the famed Angkor complex, and 3 in Takeo, which borders Viet Nam), recorded in 3 local chicken farms, 3 layer farms, 2 broiler farms, 1 duck flock and 1 wildlife rescue centre (zoo) with raptors, herons, crows, etc. The total  Number of cases was 4799; 6125 animals were destroyed^ref. 2 more outbreaks, leading the total to 12, were recorded later than 17 Mar 2004 in northeastern Kampong Cham and southern Takeo provinces, both bordering Viet Nam. 14 231 chickens, ducks, and swans had died from bird flu in the kingdom, while more than 6000 birds had been culled (Cambodian authorities cannot undertake the mass cullings that other countries have initiated to control the virus due to most livestock being owned communally). On 9 May 2004 4 birds were reported to be sick in Takeo Province. A farm located about 5 km (3 miles) outside Phnom Pen was closed after about 2300 chickens fell ill and started dying of bird flu on Sat 18 Sep, apparently the 1st cases of the disease in the country following an epidemic in Asia earlier in 2004 : the remaining 2200 birds at the farm were destroyed on 22 Sep 2004 and earlier in the 4th week of Sep. There has been no outbreak reported since October 2004. The passive surveillance system found 3 suspected cases that were investigated in May-July 2004, due to a possible link with suspected human cases. An active surveillance program for markets was launched in early August 2004 in the major live bird markets in the town. Monitoring of repopulated farms has been proposed for previously infected farms, and for farms located within a 3 km radius of outbreaks, to declare those places free of disease, and some farms are being used as sentinel farms in the country. The central epidemiology team has visited every province involved in this monitoring. Monitoring has already started in Phnom Penh and Kandal provinces. The identification and geo-referencing of commercial and semi-commercial farms in the outbreak areas (3-4 km around the outbreak) has been initiated and will be extended to the whole country. The data collected will be shared with the statistics department of the Ministry of Agriculture. A study based on interviews of citizens suggests that many villages around the outbreak sites faced an HPAI outbreak. Preliminary results also suggest that the spread of the virus was higher among "village poultry" than between independent farms. Possible explanations for the absence of new outbreaks since last April 2004 are: very high temperatures from mid-April to mid-May; the very high case fatality rate in chickens (often reaching 100%) prevented birds from acting as virus carriers; drastic reductions in animal movements in the country and the number of live birds in markets; and the low human and animal population density in the country. Many ducks are reared for egg production in rice fields and are quite separate from the local chickens. Looking at the regional map^ref, it seems almost impossible that Cambodia (and, for that matter, also Laos), situated between 2 heavily infected countries, Thailand and Vietnam, could remain unaffected by a disease spread by avian fauna. In view of official confirmation of the 1st human case of avian influenza in Cambodia, one cannot escape reflecting upon the Thai chronology. On 23 Feb 2004 Thailand officially reported the 1st case of HPAI in poultry, a day after the reporting of the 1st suspected human case. 3 fatal cases were reported from southern province of Kampot bordering Vietnam :
• a 14-year-old man from a village become sick on mid-January, went to a doctor for treatment, and died on Jan 21 from respiratory failure before he could be rushed to a hospital. In December the 50 chickens - 5 hens and the rest chicks - of his father fell sick for a few hours and then died 2 or 3 every day for 20 days, ending in early January 2005. Outbreaks of the virus were last detected in Cambodia in September 2004. No human casualties have been reported there.
• her 25-year-old sister developed respiratory symptoms on 21 Jan. She was admitted at a local Cambodian clinic in Kampot, which is about 5 km from the Vietnamese border, sought medical care in neighbouring Viet Nam on 27 Jan, and was admitted with a high fever and cough on Jan 28 to a hospital in Kien Giang's province capital, Rach Gia, 250 km (155 miles) southwest of Ho Chi Minh City, which borders Cambodia. She had slaughtered fowls for meal 2 weeks before. Tests undertaken at the Pasteur Institute, Ho Chi Minh City, Viet Nam on 1 Feb 2005 were positive for influenza A/H₅. She is the first human case of H₅ infection reported from Cambodia.
• other members of the family were suffering from high fevers and respiratory problems but no avian influenza A (H₅N₁) virus was found among 7 relatives as well as the family's fowl
• a 28-year-old man (Meas Ran) from Tram Sasor village, Bantey Meas district (only 20 km away from the first victim), first fell ill in Keatha Vong Leu village on 17 Mar 2005, was hospitalized in Phnom Penh on 21 Mar, and died on 22 Mar 205 of bird flu : the same day, laboratory tests by the Pasteur Institute in Phnom Penh confirmed that the man was infected with avian influenza A (H₅N₁) virus. Between 400 and 500 chickens and ducks had died in the village, but it was not known whether the deceased, who worked as a traveling businessman and occasionally went to Viet Nam, had been in contact with them. He added that 8 people who had been in contact with the victim tested negative for bird flu but.  Hospital staff in contact with the victim had also tested negative. > 600 chickens had died in 6 villages in Kampot in the last 20 days and a further 100 had been culled on Wed 23 Mar 2005
• test results on an 18-year-old boy (Hon Sopheap) bird flu suspect in the southern province of Kampot, home to both previous cases, had proved negative on Mar 25
• a 8-year-old girl from Tram Sasor village, Bantey Meas district, became ill with a fever on the 29 Mar 2005. Her condition deteriorated rapidly on 7 Apr 2005, when she was taken to a district referral hospital and then transferred to privately-funded Kuntha Bopha Hospital in Phnom Penh, where she died on Apr 7 2005 night and was confirmed : she was in contact with chickens when they were dying in February 2005 butnot in the 2 weeks preceding onset of symptoms, so the exposure period is too long, so epidemiologists are looking at the potential role of ducks as asymptomatic carriers. 13 people who had been in contact with the victim -- 4 family members and 9 hospital workers -- were being tested for the virus, but none were suffering symptoms, and the results were expected to be negative
• a 20 year old girl, a secondary school student and part-time poultry seller from Kompong Trach district in Kampot province (the same district as the 1st case reported from Cambodia in February 2005) was taken across the nearby Vietnamese border on Tue 19 Apr 2005 suffering a high fever and respiratory problems and was rushed to a Vietnamese hospital in Kien Giang with suspected AI, was connected to a respirator, but died on 20 Apr. The girl's relatives said chickens had died of unknown causes near her home and she ate chicken 8 days before falling ill. Swab samples taken from the woman tested positive at Ho Chi Minh City's Pasteur Institute, 250 km (155 miles) away. There was no mortality of poultry in her village, but poultry deaths occurred in a village where the woman used to go to school. In Kampol Meas village, poultry deaths were observed in late March/early April and continued into Khmer New Year (14-15 Apr 2005). A couple of chickens also died in nearby Phnom Srongab village.
Cambodia's last official report to the OIE (Follow-up report No. 3) on the occurrence of HPAI was received on 22 Sep 2004. It included data on an outbreak in a broiler farm in Kean Svay district, Kandal province, where avian influenza A (H₅N₁) virus was identified^ref. No official reports on later outbreaks are available. Follow-up report No. 4 (1 Apr 2005) decribed outbreaks in backyard chickens in Kro Peuha, Takmao district, Kandal province, about 12 km south from the capital Phnom Penh, (70 deaths and 35 destroyed since Feb 2), and Kia Thavong Leu, Banteay Meas district, Kompot province (19 deaths and 19 destroyed since Mar 24). Last known outbreak: 22-28 Mar 2005. A total of 139 chickens and ducks have been culled in Keatha Vong Leu village near the Vietnamese border.
In Cambodia, authorities on Wed Sep 21, 2005 sprayed vaccine at 7 north western farms containing nearly 16,000 ducks as a precaution after a mystery illness decimated the flocks, even though tests so far had proved negative for bird flu. A senior official from the agriculture ministry's department of animal health confirmed local media reports that concerned duck farmers had first reported mass deaths and illness in the flocks at farms just outside the north western city of Battambang on 11 Sep 2005. Despite initial tests proving negative for the H₅N₁ strain of bird flu, the birds were continuing to die in significant numbers and no cause had as yet been identified. They are spraying the farms as a precaution because the results returned on 13 Sep from initial tests were negative for H₅N₁, as were tests results returned to us from the lab on Sep 20, but ducks there are still dying : the 7 farms under observation supported around 15,480 ducks, and Battambang, which lies just 20 km to the south of the affected farms, is a major transport hub for livestock and goods arriving from the nearby border with Thailand. At least 1000 ducks had succumbed to the mystery illness in the past week^ref.
Since January, National Animal Health and Production Investigation Center (NAHPIC) introduced 30 sentinel ducks in 3 flocks in Kampong Seim district of the eastern province of Kampong Cham Province, about 50 miles (80 km) east of Phnom Penh, around Boeung Thom Lake to detect H₅N₁ virus circulation in the zone, by collecting blood and swab samples every 2 weeks. On 6 Feb 2006, 5 sera in 1 flock were tested positive, and H₅N₁ was confirmed in 1 swab sample by PCR at the Pasteur Institute. An intersectoral meeting was held, and Department of Animal Health and Production of the Ministry of Agriculture, Forestry and Fisheries decided to implement culling of the remaining 200 ducks in the infected flock, disinfection of all duck flocks' premises and surroundings in the Lake zone. The government had banned the movement of 10 000 ducks being raised near the 12 square km (4.6 square mile) lake, home to water fowl believed capable of spreading the virus without falling ill. Samples were collected before culling. In addition, investigation and sampling has been conducted to assess virus circulation in 3 villages in the Lake zone to clarify H₅N₁ epidemiology in free-ranging duck flocks and no infection was found in the nearby village. The government of impoverished Cambodia was trying to persuade other duck raisers in the area to kill their birds but could not afford to pay them to do it^{ref1, ref2}.
• a 3-year-old girl who lived in Phum Prich village in Kampong Speu Province, about 40 miles (60 km) west of the capital Phnom Penh, developed fever on March 14, was hospitalized in Phnom Penh on Mar 20 and died on Tue Mar 21, 2006 a few days after playing with sick birds and tested positive for H₅N₁. The child is known to have played with chickens, including some showing signs of illness, but an agriculture ministry official said on Sat 25 Mar 2006 that there was no evidence yet the poultry died of H₅N₁ virus infection.Cambodia's last outbreak of avian influenza in humans occurred in early 2005, while the virus has been found in ducks in eastern Kampong Cham province twice since February 2006, triggering the slaughter of hundreds of birds. Thousands of birds smuggled in from neighboring Viet Nam, where 42 people have died from bird flu since December 2004, have also been destroyed in recent months. A team from the WHO and the Health Ministry found 7 residents of the village who developed fever the same day the girl died, but none of the respiratory symptoms typical of the disease, and they all tested negative^ref. All had a history of recent contact with diseased birds or had been involved in caring for the child : although none of these people presently shows symptoms compatible with H₅N₁ infection, all have been placed under medical observation as a precaution^{ref1, ref2}. Another 42 people from Phum Prich who came into contact with the dead girl or the suspected cases have also tested negative for H₅N₁^ref. The child's 23-year-old mother said she still had no idea what had killed her daughter, an indication that bird flu public education campaigns in one of Asia's poorest nations still have a long way to go^{ref1, ref2}
• 1 adult and 2 children are being treated for fever and respiratory problems at a hospital in the capital Phnom Penh. 5 other people who had contact with the suspected cases are also being tested. It is unknown how the 3 might have become infected with the H₅N₁ virus^ref
• a 12-year-old boy from southeastern province of Prey Veng^ref, which borders Viet Nam, developed symptoms of fever and headache on 29 Mar 2006. He was initially treated at a private clinic, then hospitalized in Calmette hospital in Phnom Penh on 4 Apr 2006. He died on Wed 5 Apr 2006. Samples from the boy tested positive for H₅N₁ infection at the Pasteur Institute in Cambodia. Numerous chicken deaths and some duck deaths were noted in the neighbourhood in recent weeks. The child reportedly gathered dead chickens for distribution to village families for consumption. The investigative team identified 25 close contacts of the child. None of these people show signs of illness at present. House-to-house surveillance for signs of influenza-like illness is continuing^{ref1, ref2, ref3}
All 6 human cases of avian influenza virus infection in Cambodia have been fatal, whereas in Thailand and Viet Nam, approximately half of all confirmed cases of AI virus infection have survived. This would suggest that some less severe cases of avian influenza virus infection in the Cambodian/Viet Nam border region may have gone unrecognized. To better understand avian-to-human transmission of H₅N₁ in Tram Sasor village, a retrospective poultry mortality survey was conducted in March 2005 and a sero-epidemiologic investigation in June 2005. Poultry surveys were conducted within a 1 km radius from the human H₅N₁ case’s household and cloacal swabs were collected from randomly selected poultry for H₅N₁ testing by rRT-PCR. A household chicken flock was considered likely to have been infected with H₅N₁ during the previous 6 months if >60% of the flock died, CFR was 100% and each young and mature bird died suddenly within 1-2 days. In June, villagers in households near the H₅N₁ case’s household were asked about exposures to poultry and poultry products in the past year and tested for H₅N₁ antibodies by microneutralization. The poultry mortality survey showed a high level of ownership: 95% (155/163) of households raised chickens; 32% (52/163) raised ducks. Based on the risk definition for H₅N₁ among poultry, 42 households were considered at risk during Jan-Mar 2005, including a cluster of 26 with a relative risk of H₅N₁ of 7.9 (p=0.001) within 30 days of the survey. H₅N₁ virus was isolated in 2 sick chickens from the household next to that of the human case. Although a high proportion of participants reported collecting dead or sick poultry (50%) and chicken faeces (47%) or plucking feathers of dead poultry (47%) during the past year, none of the 351 participants from 93 households had neutralizing antibodies suggestive of H₅N₁ virus infection (Buchy, P. Low Frequency of Avian-to-human Transmission of H₅N₁ in Southern Cambodia, 2005. ICEID 2006 Abstract 68^ref). Even a doctor who was involved in a difficult process to insert a ventilator tube into the windpipe of an H₅N₁ patient did not became infected : the doctor wore no protective gear, because he didn't realize what his patient was suffering from. It was also true with several other doctors and nurses, and none of them were positive. Blood samples taken from 2 veterinarians who had autopsied birds that had died from H₅N₁ without any precautions were negative, too^ref. 2 outbreaks of HPAI have been reported in^ref :
• Tuol Prich village, Moha Russei commune, Kong Pisey district, Kompong Speu province. Number of animals in the outbreak: susceptible: 700 cases: 402; deaths: 402; destroyed: 200. Affected population: backyard chickens.
• Kamakor village, Samlanh commune, Angkor Chey district, Kompot province. Number of animals in the outbreak : susceptible: 247; cases: 76; deaths: 76; destroyed: 171. Affected population: backyard ducks and free-ranging ducks^ref.
Cambodia's last report to the OIE was sent a year ago, namely on 1 Apr 2005^ref. Since 20 Mar 2006 an outbreak in Kompong Speu (Tuol Prich) killed 402 backyard chickens and another outbreak in Kompot (Kamakor) 76 backyard ducks and free-ranging ducks.  Kompong Speu is a large province which is home to the capital, Phnom Pnen and Kompot is to the south, bordering the gulf of Thailand^ref.
• Hong Kong : a total of 5 outbreaks of H₅N₁ were detected during Dec 2002 and Jan 2003 in poultry markets and farms. No further cases have been detected since 31 Jan 2003. 3 outbreaks in parks, Nov-Dec 2002 (the virus from the waterfowl and little egrets at Penfold Park were genetically distinct from the viruses from Kowloon Park and the other wild bird viruses^ref) : the current strain resembles the one spotted Penfold Park (it appears to replicate more successfully than usual in ducks, infects a wide range of wild birds, and is shed orally as well as in faeces -- all characteristics that help it spread). Swab and tissue samples from a dead grey heron (Ardea cinerea), found on Nov 1 2004 by a worker at a construction site of ecological mitigation area of the Lok Ma Chau Spur Line Project within the restricted area near the mainland China border, tested positive for the H₅N₁ virus on Nov 3 : it is an abundant winter visitor, but a scarce summer visitor, in Hong Kong (it is not a resident species in Hong Kong). Another grey heron (Ardea cinerea) collected for isolation and observation in the same place on 3 Dec died on 4 Dec, submission for post-mortem and virological examination was undertaken on 8 Dec; sampling was carried out on 9 Dec; was confirmed as an H₅ avian flu suspect on 11 Dec, and tested positive for the H₅N₁ virus on 14 Dec (estimated date of primary infection: between 27 Nov and 1 Dec 2004). All 6 staff who had contact with the bird are in good health. The grey heron is an abundant winter visitor to Hong Kong but not a resident species. About 1200 grey herons were recorded in the Deep Bay area of Hong Kong in a survey conducted in the winter of 2003-04. Grey herons are found in a range of habitats such as marshes, tidal mudflats, estuaries, rice fields and flood plains. They feed mainly on fish but also eat amphibians, molluscs, crustaceans, aquatic insects, snakes and small rodents. No spread has been detected. Extensive virus culture and surveillance is conducted in wholesale and retail poultry markets and in bird parks and wild bird populations throughout Hong Kong. Since January 2004, 1,325 dead birds and 14,200 environmental swabs from wholesale and retail bird markets have been tested and no evidence of H₅N₁ has been detected. In addition, > 6900 samples from wild birds, 4500 captive birds in parks and 5100 pet birds have been tested by Agriculture Fisheries and Conservation Department (AFCD) and Hong Kong University (HKU) as part of the AI surveillance programme. The only 3 cases of H₅N₁ infection detected in 2004 were the peregrine falcon reported on 19 Jan (see under China), the grey heron reported on 3 Nov and this grey heron, all migratory wild birds. There have been no abnormal deaths in all 20 poultry farms within 5 km of the location, and the chickens show no symptoms of bird flu, possibly reflect the efficacy of the  heterologous (H₅N₂) vaccine, compulsorily used in Hong Kong within the application of a DIVA^ref. A "Chinese pond heron" (Ardeola bacchus) was found dead in the New Territories ecological mitigation area of Lok Ma Chau Spur Line Project 1 on 10/01/05. Avian influenza virus subtype H₅N₁ was confirmed in the heron. Genetic sequencing of the hemagglutinin cleavage site is to be conducted. All poultry farms within 5 km of where the heron was found have been checked and no unusual mortalities or illness were detected. An H₅N₁-infected dead heron was also detected in Cambodia in January 2004. In fact, we don't know at this time whether this virus is genetically the same as the one isolated from Viet Nam and Thailand. The genetic characterization is still in progress. However, the H₅N₁ virus isolated from a grey heron at the same location in early November 2004 was genetically different from the Viet Nam/Thai isolates, and there is no evidence for this virus infecting humans. There are > 60 individual biosecurity measures in place on the farms (or relating to movements of birds, people or materials to and from farms) that now form part of the license conditions for chicken farms in Hong Kong. All chicken farms are routinely vaccinated with inactivated H₅N₂vaccine and a DIVA strategy is in place that involves the inclusion of 60 individually identified unvaccinated sentinel birds within every batch of vaccinated chickens on farms. The sentinel birds are checked and tested serologically within 5 days of sale of each batch to confirm the absence of infection in the vaccinated flock. Risk perception^ref. In 2006, 16 birds tested positive for H₅N₁ :
• an adult male oriental magpie robin (a resident species), Copsychus saularis (Order: Passeriformes, Family: Muscicapidae) found dead on 10 Jan 2006 by a villager in Kam Shan Tsuen, Tai Po, a rural bush area of the New Territories in Hong Kong tested positive for H₅N₁ on Thu 19 Jan 2006^{ref1, ref2}. The oriental magpie robin is an insectivorous species which is a resident breeder in tropical southern Asia : it is distributed in the Indian subcontinent, Southeast Asia, Indochina, the Philippines, the Andamans, Greater Sundas and southern China south of the Yangtze River. This bird is a common resident in Hong Kong. It inhabits a wide range of habitats, such as gardens/parks, villages, secondary forests, open forests and mangroves. Insects are the main diet of the bird. It is a commonly found species in Hong Kong; according to birdwatchers, usually seen at large urban parks and the countryside, such as Victoria Peak, Kowloon Park, Mai Po Marshes, and Tai am Country Park; it is protected by law^ref. We are not aware of earlier recordings of HPAI H₅N₁ in the oriental magpie robin. However, several other passerines have been reportedly been infected, namely: house finch, jungle crow, black drongo, hill mynah, red-billed leiothrix, scaly-breasted munia, black-naped oriole, house sparrow, Eurasian tree-sparrow, Korean magpie, European starling, and zebra finch. A second magpie robin was found dead on Thu Jan 26 in a privately owned hut (Sheung Wo Hang Tsuen) in an area called Sha Tau Kok, not far from the border with China, Tuen Mun district of the mainly rural New Territories and tested positive for H₅N₁ strain of the virus on Jan 29 : 6 members of the family who own the house near where the bird was found were found not to have any symptoms of the disease, but were placed under medical watch^ref. 13 people in Hong Kong are under medical surveillance, after a wild bird that died of a suspected H₅ influenza infection was found in a village hut in an area bordering Shenzhen. The Centre for Health Protection is examining 6 front line staff from the Agriculture, Fisheries and Conservation Department (AFCD) and 7 family members who own the village house and hut where the bird was found. However, none had any symptoms of disease. All poultry farms within 5 km of where the Oriental magpie robin was found have been checked, and no unusual mortality or illness was detected. An intensive surveillance system is in place on all poultry farms and other locations. Local poultry farms are routinely under a constant monitoring and surveillance program involving serological and virological testing and have individual farm biosecurity plans, which include bird-proofing of all sheds. All chicken farms are routinely vaccinated with inactivated H₅N₂ vaccine, and each batch of chickens has 60 unvaccinated individually identified sentinels, which are monitored over the production life of the batch. Extensive virus culture and surveillance is conducted in wholesale and retail poultry markets and in bird parks and wild bird populations throughout Hong Kong. In 2005, over 9800 fecal or cloacal/tracheal swabs from local poultry farms, 14,100 from wholesale or retail live poultry markets, 2900 from waterfowl and aviaries in recreational parks, 3000 from pet bird shops and markets and 9000 from wild birds were tested in Hong Kong as part of the avian influenza surveillance program. The only case of H₅N₁ infection detected was the Chinese pond heron reported on 14 Jan 2005. In the past 3 months, over 1600 wild bird carcasses collected from various locations were tested, and the only positive case was this one. There were no reports of unusual mortality in wild birds. Ongoing territory-wide surveillance is continuing. Information received on 25 Jan 2006 from the Director of the Agriculture, Fisheries and Conservation Department (AFCD), Hong Kong: The virus was confirmed as a highly pathogenic H₅N₁ isolate by PCR and sequencing of the HA connecting peptide region. Molecular analysis showed that the HA protein of A/MRb/HK/75/06 [H₅N₁] has the multiple basic amino acids to satisfy the motif of a HPAI virus for chickens, but there is a deletion in the 2nd to last position of the connecting peptide (LRERRRK-R). Phylogenetic analysis showed that A/MRb/HK/75/06 [H₅N₁] belongs to H₅N₁ genotype V, which has previously been recorded in southern China, Japan and South Korea. Genotype V differs from the dominant genotype Z, which is widespread throughout Asia, in the source of the PA gene. The H5-HA gene of this virus has high homology (98%) to the HA gene of A/Dk/Hunan/5806/03 [H₅N₁]. There are no changes from A/Gs/GD/1/96 at the receptor binding sites of the hemagglutinin. The NA gene has the 20 amino acid deletion that is characteristic of genotype Z H₅N₁ viruses. The M gene has Ser at position 31 and has no other mutations that are known to confer amantadine resistance. The NS1 gene has the 5 amino acid deletion seen in genotype Z viruses and has Asp at position 92. The PB2 gene has Glu at position 627
• on Feb 1, 2006, 2 dead birds -- a wild crested myna (Acridotheres cristatellus),  found dead in an urban playground^ref and a domestic chicken (Gallus gallus) smuggled in from mainland China -- tested positive for H₅N₁ virus : authorities do not know whether the chicken was infected in the mainland or whether it was infected in Hong Kong. The bird was smuggled into Hong Kong on 26 Jan 2006 without symptoms and became ill on 31 Jan 2006. The typical incubation period for the disease in birds is 2 to 10 days. The chicken was brought illegally into Hong Kong ahead of the Lunar New Year period. Despite bird flu worries, the government increased the number of chickens shipped into Hong Kong from mainland China around the 29 Jan 2006 Lunar New Year. The chicken fell ill and died about half a km (0.3 miles) from the border with China in an area where on 29 Jan 2006 an Oriental magpie robin also died of H₅N₁. 3 asymptomatic people in Sha Tau Kok village on the border with mainland China (a 42-year-old man, his 79-year-old mother and a 39-year-old female relative) were treated with oseltamivir and placed in an isolation ward of a hospital in the Hong Kong S.A.R. of China after it was found another chicken brought from China they had contact (killed and eaten) during a family feast had nested with the infected chicken^ref. They have shown no signs of infection, as further tests are carried out^ref. It is unlikely that these 3 patients will be found to have contracted bird flu, as infection cannot contracted directly from eat-processed chicken, and it is not certain that the bird itself was infected (only in contact with a diseased bird). As a precaution, the government will cull all poultry within 5 km (3.1 miles) of the small holding where the chicken died and also close the city's walk-in aviaries and a large nature reserve. Household poultry-keeping is set to be banned to reduce the risk of a bird flu outbreak in Hong Kong^ref. With the introduction of the legislative amendments that came into force on Feb. 13, 2006, households will not be allowed to keep any backyard poultry. Unauthorized keeping of 5 kinds of live poultry (chickens, ducks, geese, pigeons and quails, while pet birds that have received injection were not included) would be an offense with a fine of 50,000 to 100,000 HK dollars (about 6,400 to 12,900 US$). Agriculture department staff have been searching homes in villages throughout the territory's rural areas in what was expected to be a 6-week programme to clear Hong Kong of an estimated 9000 chickens and 3500 ducks kept in homes^ref
• late on Wed 8 Feb 2006 a dead egret found earlier this week in an urban Hong Kong district has tested positive for the deadly H₅N₁ strain of bird flu
• a dead chicken (Gallus gallus) and on a Japanese white-eye [Zosterops japonica simplex^ref], a small wild bird found near a local school, tested positive for H₅N₁ on 10 Feb 2006
• on Thu 9 Feb, officials collected another dead bird, a red-whiskered bulbul [Pycnonotus jocosus^ref], in the same area. It will be tested for avian flu but wasn't yet considered a suspect case^ref.
• a common magpie (Pica pica sericea^ref) found dead on Thu Feb 16 in Sham Shui Po, a district crammed with open-air markets, run-down residential buildings and often unsanitary alleyways, tested positive for the H₅N₁ on Sat, 18 Feb 2006. It was the 9th bird to be found infected with the disease since late January 2006 in Hong Kong.
• another common magpie found dead on Fri Feb 17 in a flower market in Mongkok district, another heavily populated district that is home to a pet bird market, tested positive for H₅N₁ on Feb 20. Magpies are common in this crowded city of nearly 7 million people and are often kept as pets^ref.
• a dead large-billed crow [Corvus macrorhynchos^ref] found in Kowloon on Sat Feb 17 and a munia [species?!]
• a white-backed (white-rumped) munia [Lonchura striata^ref] discovered separately on Hong Kong island on Sun Feb 18, 2006.
• a house crow (Corvus splendens) found on Thu 23 Feb 2006 in Shek Kip Mei in the Kowloon area, indicated a suspected case of H₅ avian influenza^ref
• little egret (Egretta garzetta)^ref
Information on H₅N₁-infected birds found in Hong Kong so far in 2006 had been uploaded onto the website of Hong Kong Agriculture, Fisheries and Conservation Department (AFCD) : chicken (2); common magpie (4); crested myna (1); house crow (2); Japanese white eye (1); large-billed crow (1); little egret (1); munia (1); Oriental magpie robins (2); white-backed munia (1).
From 2005 to the end of February 2006, > 11,400 fecal or cloacal/tracheal swabs from local poultry farms, 15,300 from wholesale or retail live poultry markets, 3200 from waterfowl and aviaries in recreational parks, 3500 from pet bird shops and markets, and 13,700 from wild birds were tested in Hong Kong as part of the avian influenza surveillance program. There have been no reports of unusual mortality in wild birds. All chicken farms are routinely vaccinated with inactivated H₅N₂ vaccine, and each batch of chickens has 60 unvaccinated individually identified sentinels, which are monitored over the production life of the batch. The H₅-HA genes of these viruses have the highest homology (99%) to each other's HA1 gene and high homology (98%) to that of A/Dk/Hunan/5806/03 (H₅N₁). Phylogenetic analysis showed that these viruses all belong to H₅N₁ genotype V, which has previously been recorded in southern China, Japan and South Korea.
Virus samples taken from the 8 wild birds and 2 stray chickens found dead with H₅N₁ in January 2006 in Hong Kong were of V-genotype, closely linked to a strain of the H₅N₁ virus that surfaced in Japan and South Korea in 2004, but not the one spreading in Europe^ref. Authorities ordered the closure of all bird parks in Hong Kong and the Mi Pu Park of Natural Reserve on 1 Feb 2006.
A cat was sent to the Society for the Prevention of Cruelty to Animals (SPCA) in Hong Kong on Wed 8 Mar 2006 : it brought home a dead bird from the garden.
Since an enhanced surveillance programme began 15 Jun 2006, the Hospital Authority e-Flu system has received 90 reports of pneumonia of an unidentified cause and who had travelled to affected areas or countries with confirmed human cases of bird flu in the 7 days before the onset of symptoms. On Jun 22, 2006, 9 cases, involving 7 men and 2 women who visited Guangdong, Hunan, Hubei, Zhejiang and Fujian provinces before the onset of symptoms^{ref1, ref2}.  While this number may sound alarming, one does not know what the baseline rate of pneumonia of unknown etiology is in Hong Kong. With a population estimated at 6.9 million, a report of 70 cases of pneumonia in one week yields a rate of approximately 1 case per 100 000 population.  In contrast, in a report on pneumonia surveillance in the state of Connecticut over a 3-year period (2001-2004), there were an average of 305 hospital admissions per week, with an increase to over 350 pneumonia cases per week during the influenza season in 2003-2004^ref. With an average population of 3.5 million during the 3-year period^ref,  the weekly pneumonia rate was an estimated 8.8 per 100 000 population. While the reported pneumonia admissions as presented in the Connecticut study did not differentiate by etiologic agent, the estimated rate in Connecticut is almost 9 times higher than that seen in Hong Kong
during the past week of active surveillance. Clearly more information from knowledgeable sources in Hong Kong would be greatly appreciated to help put the above reports into perspective
• Macao : 140 dead bird reports were registered since October 2005 to Feb 4 2006 but none of the cases tested positive for the avian flu up to now^ref
• Indonesia^{ref1, ref2, ref3, ref4} (a sprawling archipelago of some 17,000 islands and 220 million people; first rumors 19 Nov 2003; first official confirmation to press, 26 Jan 2004, indicating H₅N₁ since Nov-Dec 2003; first official notification to OIE : 3 Feb) : about 60% of 4.7 million chickens that have died since August 2003 were infected by Newcastle disease while 40% of them were infected with AI and Newcastle disease. It first hit the Central Java provincial town of Pekalongan on 29 Aug 2003. The disease later spread to at least 400 farms in Central Java, with 127 outbreaks in 80 districts within 10 provinces :
• Banten province (1 district)/ 12
• West Java province (6 districts)/ 12
• Central Java province (17 districts)/ 26
• Jakarta province (1 district)/ 1
• Yogyakarta province (3 districts)/ 8
• East Java province (13 districts)/ 26
• Lampung province (3 districts)/ 4
• Bali province (5 districts)/ 30
• South Kalimantan (1 district)/ 1
• Central Kalimantan (1 district)/ 1
• South Sumatra (6 districts)/ 6
Estimated date of primary infection, according to this notification, was 11 Dec 2003; date of initial detection of animal health incident: 15 Dec 2003. Indonesia is an archipelago comprising > 17,000 islands of  which approximately 6,000 are inhabited and 1,000 have permanent settlements. The current situation with AI is now involving provinces on 4 of the larger islands -- Bali, Java (West Java, Central Java, East Java and Yogyakarta), Sumatra (Lampung), and now Borneo (West Kalimantan). There are 3 countries that share territory on the island of Borneo -- Indonesia, Malaysia and Brunei. The newly infected Province, West Kalimantan borders with Sarawak, Malaysia. On Mar 20, 2004 the virus had extended its range in southern Sumatra, while West Kalimantan recently became the latest province to be infected with the AI influenza : the disease is strongly suspected to have also spread to Lombok, Sumbawa, Flores, and West Timor. Among the 11 provinces that had previously reported bird flu cases, 5 provinces reported 0 cases in February 2004, while only 14 regencies were affected, down from 51 in Jan 2004. In addition, the total number of chickens dying of bird flu dropped to 1.2 million in January 2004 and to 966,000 in February after reaching the highest level of 1.6 million in December 2003 : it is true that West Kalimantan was added to the list recently, but Banten, Jakarta, West Java, South Kalimantan, and Lampung have not reported any cases in February 2004. According to data from the ministry, the 6 provinces that reported bird flu cases in February 2004 were Central Java with 527 319 cases, Yogyakarta 31 075 cases, East Java 65 161 cases, Bali 333 268 cases, Central Kalimantan 4279 cases, and West Kalimantan 5770 cases. The official death toll of chickens has been estimated at 6.2 million as of the end of Feb 2004 (this figure excludes those chickens that were culled), and the number of chickens culled estimated at 2.5 million. However, the FAO estimates that a total of 15 million chickens have died or been culled.
Around 16 million fowl, out of a population of around one billion, have died in Indonesia since the end of 2003 due to AI and Newcastle disease.
Indonesia's Agriculture Ministry faced criticism Fri 6 Feb 2004 for allowing 30 million doses of an unaccredited and allegedly ineffective bird flu vaccine imported from China by Bio Farma to enter the country. While the need in Indonesia is 120 million doses per month, the local production capacity in Indonesia is currently 47 million doses per month. In the 6-month period until 31 Jul 2004 the Indonesian government will import 184 million vaccine doses from China and the rest of the world.
The RNA of Indonesian virus is similar to the kind in the Yunan province on mainland China, and distinct from that in Viet Nam and Thailand.
Suspected human case : 3-year-old son whose mother worked at an infected chicken farm in the Tabanan district on the resort island of Bali died.
On April 2004 : new outbreaks in 1 district in Central Java Province and 2 districts in Bali Province.
New cases in 4 previously infected districts occurred at the end of May 2004 and were reported between 1 and 16 Jun 2004. They are Musi Rawas (South Sumatra province), Gunung Kidul (regional area of DI Yogyakarta), Demak and Purworejo (Central Java province). The new cases in Central Java, and DI Yogyakarta. The total number of infected provinces is 14, comprising 92 districts. The disease hit a chicken farm in Grobogan District, Central Java in the final week of Sep 2004, killing 350 of 1500 birds.
On December 2004 HPAI H₅N₁ broke out in several parts of West Nusa Tenggara (NTB) [Nusa Tenggara Barat], killing > 20,000 birds, or 43% of the poultry population in 10 out of the 23 subdistricts in the provincial capital of Mataram, South-east Indonesia, < 100 km east of Bali. The outbreak was less severe in the other 13 subdistricts, where about 10% of the total poultry population was affected. The virus is believed to have been introduced by poultry from the neighboring island of Bali or from Sulawesi [> 600 km north-west of Mataram]^ref. According to OIE's statistics summarizing the number of outbreaks accumulated since the beginning of the Eastern-Asia epizootic in early 2004, Indonesia ranks 3rd, with 169 foci, following 1749 in Viet Nam, and 994 in Thailand^ref.
Bird flu resurfaced in Indonesia, killing at least 21,000 chickens on farms in 5 regencies and municipalities in the province of West Java over the last 2 months (Cirebon regency and municipality, Subang regency, Indramayu regency and Sukabumi regency). Cirebon municipality had the most reported cases of bird flu, with about 12,000 chickens killed by the H₅N₁and H₇N₁ viruses. During 2004, bird flu was reported in 10 areas in West Java and killed about 1.6 million out of 6 million farmed chickens in the province, or 25.3%. They have prepared 50 million doses of vaccine to stop the spread of the virus in 2005. According to estimates from the FAO, which were announced during a recent 28-nation conference on bird flu in Vietnam, bird flu cost Asian farmers and agricultural industries 10 billion USD in 2004. Indonesia's last avian influenza case was recorded on 13 Dec 2004. According to OIE's data, the 4 countries suffering the highest number of HPAI outbreaks since the beginning of the panzootic in Dec 2003, are (in brackets -- accumulated number of outbreaks as of 25 Feb 2005): Viet Nam --1764; Thailand -- 1077; Indonesia -- 169; China -- 50. The respective dates of their last follow-up reports to the OIE are: 22 Feb 2005; 24 Feb 2005; 6 Oct 2004; 6 Jul 2004. Absence of report does not necessarily indicate the absence of disease. According to a reportage (allegedly from an official source), bird flu has been killing > 33,000 chickens on farms in West Java in Jan and Feb 2005 : this might mean that the outbreak has been continuing without an interval but remained unreported to the OIE. Reporting can trigger difficult consequences. Many countries find it difficult to report outbreaks of contagious diseases because these can impact trade and tourism, or it can injure their international standing or self-image. The Central Government decided to isolate South Sulawesi in February 2005 and West Java in January 2005 from chicken trading, as a fresh outbreak of bird flu killed some 25,000 chickens the 2nd week March 2005 in the regencies of Maros, Sidrap, Wajo, Pinrang, Soppeng & Parepare: government had also distributed some 200 000 doses of a locally produced vaccine to try and stop the disease from spreading. Indonesia sent its last follow-up report, No. 7, to the OIE on 10 Mar 2005, indicating H₅N₁ outbreaks in 2 districts -- Wajo and Soppeng -- in the Sulawesi Selatan Province. According to the report, the disease, affecting native chicken layers and broilers, was introduced by illegal movement of animals from neighboring countries (imported fighting cocks). Official information on the situation in West Java will help. According to the previous follow-up report, 6 Oct 2004, the outbreaks were in East and central Java. For an administrative map of Indonesia^ref. 60 000 quail (out of 130,000 farmed) had either died from H₅N₁ or had been culled at farms in Central Java provincea since February 2005. In the January-March 2005 period, bird flu had killed a total of 281 730 fowl in 3 provinces of South Sulawesi, West Java and Central Java. Indonesia's last HPAI follow-up report, received by the OIE on 10 Mar 2005, referred to outbreaks in Sulawesi Selatan Province, reportedly caused by HPAI virus subtype H₅N₁. The outbreaks that, according to the current newswire, have taken place during January-March 2005 in West Java and Central Java have yet to be officially reported. In case genetic studies of Indonesian H₅N₁ virus strains are being carried out, their results will be of interest, in particular, data on the relationship of these strains to other recent Asian H₅N₁ virus strains and their virulence to various avian and mammal species.
Ca Nidom, a molecular biology researcher from the Centre for Tropical Disease Control, Airlangga University, Surabaya, East Java, has reportedly identified avian influenza virus by RT-PCR in throat swabs and sera of 10 out of 20 asymptomatic pigs living 100 yards away from a chicken farm in Surabaya on Java island that was struck by bird flu during 2004 : inactivated RNA isolates have been sent to the Tokyo University, where 8 fragments (HA, NA,  PA, PB1, PB2, M, NP, NS) were sequenced. It is the same "HPAI" variant (based on the study regarding the cleavage site) that causes severe disease in chickens. And the isolated virus's gene for haemagglutinin was > 98% identical to samples taken from infected Indonesian chickens and quail. Traces of H₅N₁ infection had been reported in 1 pig in Vietnam and 2 in China in 2004, but this is the 1st time that a virus isolated from a natural infection in pigs has been genetically sequenced. Could culled chickens be used (illegally, of course) as food for pigs? Farmers hate to waste anything and might not understand the finer points of infectious disease transmission. Feeding of chicken manure, often including chicken carcasses or parts thereof, to food animals -- herbivores included -- has been widely practiced in many countries. Most countries require that the recycled material be derived only from farms considered free of infectious diseases. Some countries allow it only in certain species and/or husbandry methods. In Bali there were 1000 chickens living over 20 pig pens with just slats between them. It is a farming system called tampung sari. This way the chickens' faeces falls directly to the pigs and they eat it. Apparently pigs can get up to 40% of the RDA from chicken faeces, and it is common practice to feed chicken faeces to pigs. To my knowledge culled chickens are not used to feed pigs (at least in tampung sari), but it is possible. It is well known that chicken faeces [i.e., feces from infected chickens] contain H₅N₁, so the exposure from chicken faeces is enough to explain the finding. Likewise, in China, ducks and pigs live closely together so that it is easy to explain the finding of H₅N₁ in pigs in China in 2004. Integrated farming systems are meant to utilize the products of one sub-system by another sub-system, generating useful materials like protein biomass in the process. Various combinations are known. In Southeast Asia, integrated systems combining chickens/ducks, pigs and fish are widely applied. The Indonesian Agriculture ministry conducted tests on pigs after local scientists reported that pigs in several farms on the main island of Java were infected.
During Jan - Mar 2005, HPAI had killed a total of 281,730 birds in Central Java, South Sulawesi and West Java Provinces. In Central Java Province, some quail farms have been affected and over 77,000 poultry have either died or been culled. The disease also attacked the native chicken in Bojolali and Sragen districts. In South Sulawesi Province, the deaths of the birds were observed in Maros, Parepare, Pinrang, Sidrap, Soppeng and Wajo Regencies. Inter-island chicken trade from South Sulawesi has been banned since mid March 2005. In West Java Province, 21,000 dead chickens were reported between Jan - early Mar in Cirebon, Subang, Indramayu, Purwakarta and Sukabumi regencies/municipalities. Cirebon municipality had the highest reported cases with about 12,000 chickens affected. No bird flu cases were reported in Cirebon in 2004. HPAI had mostly affected quails in West Java. In Cirebon, destroyed quails were said to have been brought from Sleman (Yogyakarta). Some 200,000 doses of vaccine against H₅N₁ infection had been distributed to infected areas, and the government has set aside Rp 750 million (USD 79 000) and Rp 250 million [USD 26 000] backup fund to assist poultry breeders who destroyed their bird flu-infected flocks. Since 31 Mar 2005, West Java authorities have stopped all poultry traffic into the area. Cirebon has been declared as an epidemic area. The poultry-check operation targeting chickens, quails and ducks was held in the Losari area, which is on the border and main route of poultry trucks from Central Java, Yogyakarta and East Java.
30 chickens were found dead recently in Sidomulya subdistrict, Samarinda, East Kalimantan near the end of April 2005.
On June 2 2005, the OIE declared H₅N₁ AI endemic in Indonesia; that means the OIE believes there is a strong chance for new widespread outbreaks of the highly virulent strain. Despite that announcement, Indonesia's government hasn't yet changed their plans to be bird flu free by 2007.
Follow-up reports : 6 Feb 2004, 5 Mar 2004, 9 Apr 2004, 14 May 2004, 2 Jul 2004, 6 Aug 2004, 8 Oct 2004, 11 Mar 2005, 8 Apr 2005
Follow-up report No.8 : 1 June 2005 : Information received on 23 May 2005 from Prof. H.R. Wasito, Director General of Livestock Services, Department of Agriculture, Jakarta: end of previous report period: 6 Apr 2005 (see Disease Information, 18 [14], 102, dated 8 Apr 2005). End of this report period: 23 May 2005. Precise identification of agent: HPAI virus subtype H₅N₁. 3 surveys were conducted in Tangerang district, Banten province, using purposive and pooled sampling. A total of 187 samples were taken during the surveys.
• the 1st survey was conducted on 23 Feb 2005 in a farm in Babat village, Legok subdistrict, where 5 out of 10 nasal swabs were positive and the subtype involved was identified as H₅N₁.
• as a follow-up, the 2nd survey was conducted on 14 Apr 2005 in Rancaiyuh village, Panongan subdistrict, where 6 out of 10 nasal swabs taken from 31 pigs over 5 months old were positive for H₅N₁.
• the 3rd survey was on 26 Apr 2005 in Babat village, Legok subdistrict, where one out of 6 nasal swabs taken from 6 pigs over one year old was positive for H₅N₁.
Not a single pig has shown clinical signs of avian influenza. Details of outbreaks:
• 1st administrative division: Jawa Barat (West Java); Lower administrative division: Banten province; Type of epidemiological unit: village; Name of the location: Legok subdistrict; Date of start of the outbreak: 24 Feb 2005; Species: sui; Number of animals in the outbreaks : susceptible: 897; cases: 6 (infected animals without clinical signs); deaths: 0; destroyed: 0; slaughtered: ...
• 1st administrative division: Jawa Barat (West Java); Lower administrative division: Banten province; Type of epidemiological unit: village; Name of the location: Panongan subdistrict; Date of start of the outbreak: 14 Apr 2005; Species: sui;  Number of animals in the outbreaks: susceptible: 823; cases: 6 (infected animals without clinical signs); deaths: 0; destroyed: 0; slaughtered: ...
Diagnosis: laboratories where diagnosis was made: Faculty of medicine, Airlangga University; Species examined: sui; Diagnostic tests used: RT-PCR (1); Date: 7 Mar 2005; Results: H₅N₁. Laboratories where diagnosis was made: Research Institute for Veterinary; Science, Bogor; Species examined: sui; Diagnostic tests used: agar-gel precipitation test, RT-PCR(1) and sequencing analysis; Date: 28 Apr 2005; Results: H₅N₁
Laboratories where diagnosis was made: Disease Investigation Centre Region I-VII; Species examined: sui; Diagnostic tests used: hemagglutination inhibition test; Date: 2 May 2005; Results: H₅N₁
Further investigations have been made in 7 provinces (Central Java, West Java, West Kalimantan, South Sulawesi, Bali, Riau and North Sumatra). The results of the serological testing of 250 samples (sera and swabs) were all negative. Source of outbreaks or origin of infection: these pig farms are adjacent to
backyard chicken farms. The infection in pigs was due to contamination with chicken manure. Control measures:
• undertaken: quarantine; movement control inside the country; disinfection of infected premises/establishment(s).
• to be undertaken: partial stamping out; no treatment of affected animals; no prohibited vaccination^ref
Details of new outbreaks: 1st administrative division (province) (in brackets: 2nd admin div):
• 1. Jambi: 7 outbreaks (3 in Batang Hari, 4 in Jambi);
• 2. Kalimantan Timur (East Kalimantan): 1 outbreak (Tenggarong) ;
• 3. Sumatera Utara ( North Sumatra): 1 outbreak (Simalungun);
(Total: 9 outbreaks between 7 Mar 2005 - 4 May 2005). Description of affected populations: layers, broilers, ducks, native poultry, fighting cocks.
A 22-year-old man (Khairil Anwar) resident of Pussanti hamlet in Sinjai regency (southern Sulawesi island) some 150 km south of Makassar city, farm worker in Soppeng regency, is healthy and currently shows no symptoms of illness but 2 tests at a Hong Kong laboratory confirmed that he had been infected by H₅N₁ AI virus, making Indonesia the 4th country to register a human case of avian influenza. The farm worker was initially tested in late March after the epidemic spread to Sulawesi, killing > 25,000 chickens. That outbreak prompted officials to limit the transfer of poultry off the island and take blood samples from laborers, veterinarians and others exposed to sick chickens. Efforts to complete a second round of testing in Hong Kong were prolonged in part because the farm worker had left his job and health investigators had to track him back to his home village elsewhere on the island. The second test, finally completed earlier this month, confirmed that the laborer had been infected by bird flu but the concentration of antibodies was relatively low, officials said. That finding meant the worker was no longer carrying the virus but it was impossible to determine how long ago he had been infected. In total, 81 people were tested and all but one of the samples came back negative. He has gone back to his hometown in the last 2 months after a poultry farm where he worked in Soppeng regency went out of business after being hit by the virus, killing 10,000 chickens in just 20 days. While working at the farm, Khairil was completely unaware of the danger of bird flu or the precautionary measures that should have been taken, such as wearing masks or gloves to shield him from infection. No officials had ever come in to provide the poultry farmers and workers with such information. He only learned there might be something wrong with him after WHO staff came to take his blood sample for the second time, all the while asking about his health condition and then gave him Rp 500,000 (US$53) to go to the doctor in case he felt sick. Since 2003, the highly lethal disease has struck chickens, quail and other birds in 18 Indonesian provinces on 7 islands. The H₅N₁ virus circulating in Indonesia is (genetically) distinct from other East Asian isolates and as a consequence may be less pathogenic in humans^ref.
A 8-year-old female living in Tangerang suburb of Banten Province, Jakarta, became ill with fever, diarrhoea, then cough, on 24 Jun 2005. She was brought to Siloam Gleneagles Hospital, Tangerang, on 28 Jun, where she died with respiratory distress 20 days after onset on Thu 14 Jul morning : her 38-yrs old father (Iwan Rapei), an auditor of the Supreme Audit Agency (BPK), who often visited her, and her 1-year-old sister developed the same symptoms on 2 Jul and 29 Jun, respectively. The 2 were admitted to the Siloam Gleneagles Hospital in Tangerang, Banten Province about 25 km (15.5 miles) west of Jakarta, on 7 Jul, for high fever and respiratory problems. The 1-year-old girl died 10 days after onset on Sat 9 Jul at the Harapan Kita Hospital in West Jakarta after being treated for 2 days. The father died 10 days after onset on Tue 12 Jul : samples from the man tested positive for avian influenza H₅N₁ virus by the WHO H₅ reference laboratories at the Department of Microbiology, University of Hong Kong, and the Centers for Disease Control and Prevention, Atlanta USA. Samples from the 2 children are being tested : on 29 Jul the same 2 labs detected high positive rising micro-neutralisation titres specific for H₅N₁ in 2 samples taken 3 days apart from the 8-year-old girl (the initial case), suggesting she was a probable avian influenza A/H₅ case, based on analysis of serological samples : on 3 Apr 2006 H₅N₁ was confirmed by the WHO lab in Hong Kong^ref. Laboratory results for the 1-year-old daughter are still pending. Genotyping of the PCR-amplified isolate from the confirmed case shows high homogeneity with other H₅N₁ isolates from poultry in Java, and no evidence of reassortment of genome sub-units. The remaining 4 residents of the house (2 members of the family and 2 household workers) remain healthy and show no symptoms to date. The restriction of the Indonesia outbreak to 3 members of one family, leaving at least 2 others unaffected, is curious. The mystery of the route of transmission of infection is further complicated by the fact that the family reside in an affluent suburban area of the capital city. The Ministry of Health is closely following over 300 contacts, including health care workers, family members, school and office colleagues and neighbours. None of these contacts has shown any symptoms to date. They also plan to carry out extensive tests on animals within a 20 km (12 mile) radius of the family's house and slaughter those infected : H₅-infected bird faeces were detected in a bird cage on the side of the road opposite the family's house; cloacal and throat swabs of the pet bird inside the cage were negative for H₅. This is the 1st, and, thus far, the only, indication of a possible source of exposure. Other environmental sampling was negative. Media reports that claimed that the affected family had just returned from India and Hong Kong have been denied : according to his passport, the father's last trip abroad was in October 2004 to Hungary without his family, adding that the deceased man was also scheduled to visit South Africa this week on business. While the 3 Indonesian family members had no known contact with poultry before they died, a more thorough investigation could turn up evidence to the contrary : on Wed 10 Aug 2005 Indonesian health authorities decided to abandon the quest. It seems quite possible to me that an infected bird -- or a bird that had recently recovered from infection -- could have been removed from the cage only hours or perhaps even minutes before inspectors arrived at the house. Given human nature and the fear of official retribution common to ordinary people in most countries of world, the bird could have been clandestinely removed or released in response to news that government inspectors were in the neighborhood checking birds for signs of possible illness. How likely is it that a false positive (as opposed to a false negative) would
be obtained from bird feces -- even if old?  Also, if this is in fact the case, why wouldn't WHO have cited reservations regarding the diagnosis in their update? No indication of the estimated age of the feces was given; it seems possible that the infected bird could have been removed only hours or even minutes before inspectors arrived at the house. However, this does not explain why only those 3 were affected, while the other family members showed negative results for both serologic and PCR tests. Also, none of the neighboring families showed a positive result. There is also a question as to whether those 3 victims were exposed to the source at the same time or whether one of them was the index case and transmitted the virus to the other close family members sharing the same genetic susceptibility to the virus. As we know, the 2nd case showed symptoms 10-11 days after the 1st, the 3rd case a few days later: an unusual incubation period for avian influenza if they were exposed at the same time. My hypothesis is that they were grossly exposed to a (so far unknown) source, possibly repeatedly. Alternatively, one victim could have become a new infection source for the others who have similar genetic susceptibility. This is an issue that deserves further study, particularly with respect to an apparent greater vulnerability of Vietnamese people to avian influenza virus infectionCould an intentional targeted spreading of the virus possibly play a role in this case? Indonesia has sent specimens to Hong Kong to confirm the results, which will take 7 to 10 days. Though there is no evidence yet that the 3 had contact with infected poultry, human-to-human transmission of the disease appeared unlikely at this stage. The virus strain that killed them had not mutated to ease such transmission. The Federation of North Sumatra Fowl Associations (Gapsu) claimed that the outbreak was caused by the distribution of hatching eggs smuggled from Malaysia (a country that hasn't really reported AI) besides the entry of chicken from areas already infected with the virus, like Java and Thailand. From 23 Aug 2004 the Indonesian government has banned the import of fowl products from Malaysia but to date, their hatching eggs can still be found in North Sumatra. 4 seaports in Batam, namely Sekupang, Batuampar, Telaga Punggar and Pusat Batam, were placed under strict surveillance to prevent the entry of items that could carry the bird flu virus including chicken eggs and dressed chicken. Other hypotheses involve a smuggled fighting cock from Thailand, and migratory birds en route to Australia. About 383,000 chickens had died of bird flu in south Sulawesi since March 2005. Bird flu outbreak has affected at least 132 regencies and cities in 21 out of 30 provinces in Indonesia with the number of chickens killed by the virus totaling 9.53 million. Further data on the suspected source of their infection have not been provided; it would help if information on possible contacts with the pig farms found infected in Tangerang earlier in 2005 becomes available. The farms were in Babat village, Legok subdistrict and Rancaiyuh village, Panongan subdistrict. The Indonesian authorities will on Sun 24 Jul 2005 kill, burn and bury some 200 pigs infected by bird flu in Tangerang.
A 37 years-old woman in Jakarta developed symptoms on 31 Aug, was admitted at the Bintaro International Hospital in South Jakarta on 3 September, suffered from pneumonia and flu-like respiratory problems since 6 Sep 2005 and died on Sat 10 Aug 2005 night, becoming the country's 5th case (4th death) of the disease : tests by the WHO reference laboratory in Hong Kong on 16 Sep were positive for H₅N₁. The woman was an immigration agent and dealt with many expatriates. Inquiries so far had found that people she had contact with were healthy. Unlike most bird flu victims, she rarely had contact with animals, but reportedly lived near a poultry slaughterhouse and some of her neighbours kept chickens and ducks. No recent poultry deaths have been reported in the area. She had a wild type H5N1 cleavage site, RERRRKKR, and was reportedly linked to fertilizer, and presented the PB2 E627K mutation. However, the only bird H₅N₁ sequences with PB2 E627K is the Qinghai strain and the description of the isolate from the second confirmed case indicated it was a clade 2 sequence, like poultry sequences in Indonesia. Therefore, none of the human sequences match a published bird sequence in the area, highlighting the need for more H₅N₁ sequences from West Java, and the need to release the existing human sequences. The acquisition of PB2 E627K could have been due to random mutation within the patient.  However, E627K could also have been acquired via recombination, since all mammalian sero-types isolated from humans have E627K.  Similarly, all Qinghai strains of H₅N₁ also have E627K. so recombination could have happened between two avian isolates. Although E627K could have also been acquired via reassortment involving avian genes, such reassortment would have probably mentioned in the WHO update. In the Qinghai strain, the wild type cleavage site is GERRRKKR, which may not be as virulent as RERRRKKR. Earlier human isolates from Hong Kong, Vietnam, and Thailand that combined the wild type H₅N₁ cleavage site with PB2 E627K were almost universally fatal. Similarly the combination in mammals, such as the tigers in the zoo in Thailand, a domestic cat or domestic dog also led to fatalities. E627K also increased virulence in laboratory mice. The infections in the tigers in Thailand also lead to efficient tiger to tiger transmission. All 147 of the exposed tigers either died or were euthanized, even though culling and Tamiflu was used to try to control the outbreak^ref.
• a neighbor of the woman had been hospitalized with symptoms consistent with avian influenza. But the authorities said they were still awaiting lab results before confirming she had contracted H₅N₁ avian influenza virus infection. 15 blood samples taken by a Health Ministry team from her relatives and neighbors (including those taken from 3 people who had helped to bury the woman) tested negative for H₅N₁on Tue 13 Sep 2005. It should be noted that, with regard to the cluster of 3 deaths in the same family referred to in the above reports, WHO has stated that H₅N₁ infection was confirmed in the 38-year-old father but that laboratory test results for his 2 daughters did not meet criteria for acute H₅N₁ infection. WHO reports only laboratory-confirmed cases. Therefore, the number of confirmed human cases of avian influenza in Indonesia is 2, not 4 as repeatedly stated by the Indonesian authorities.
The estimated number of chickens killed by avian influenza in Indonesia is 9.5 million, whereas the number of animals culled in 2005 is 71. The virus has spread to 22 provinces out of 33 in the sprawling Indonesian archipelago, killing more than 9.5 million poultry since late 2003.
The the 140 hectare Ragunan zoo in south Jakarta was shut on Sep 19, 2005 after 19 out of 27 birds (including peacocks, mynahs, wild ducks, pigmy chickens, eagles, and herons) that were randomly tested were found infected with AI : it was closed to the public through Oct 11. Usually 2 weeks are enough but they decided to raise it to 3 weeks to make sure unwanted things would not happen : some 2,100 birds in the zoo's collection will be tested for the virus. An important question is how did the virus get there? Was it spread from migratory birds; did someone illegally bring and feed infected poultry arcasses to animals in the collection? Was it spread mechanically from poultry either in Jakarta or outside the city, as people do visit important zoos often and from substantial distances? The report also underscores the importance of including zoos in a comprehensive surveillance strategy for avian influenza, and other diseases. The inclusion of information derived from a zoo was critical in unraveling the 1999 West Nile incursion into New York City in the USA. No better example of the benefits of zoo surveillance could be found than the key observations and subsequent isolation of West Nile virus spearheaded by Tracy McNamara at the Bronx Zoo, when she noted that the pattern of mortality in her zoo collection was not likely to be due to St Louis encephalitis, the prevailing presumptive diagnosis for the human cases early in the West Nile outbreak in New York City. Seeing the pattern of occurrence in all animals can be very helpful. Zoos provide a wide range of species, which may have varying susceptibilities for new agents or strains. It is, therefore, imperative that surveillance at zoos be one element, along with surveillance in humans, pet bird populations, backyard poultry, commercial poultry and, of course, migratory birds, swine and other species in a comprehensive surveillance strategy. How to optimize surveillance in terms of cost, time and personnel is, of course, a key decision for responsible human and animal health authorities. Management of avian zoo population, now that avian influenza has been found in the collection, presents real dilemmas and significant tradeoffs. Although I don't know the status of the zoo collection presently, it is my understanding that this zoo is likely to contain several species that are very rare and qualify for special treatment under the CITES (Convention on International Trade in Endangered Species) treaty, which protects endangered species. Birds such as Argus pheasants, Bali mynahs and Birds of Paradise are likely to be included at a key zoo location such as the Ragunan Zoo. Depopulation, particularly as exemplified in Hong Kong in 1997, has been one of the most effective public health measures taken when avian influenza-infected live birds exist in urban markets. In this case, however, depopulation should be a last resort, not a knee jerk reaction. A plan for quarantining and testing selected rare, positive or exposed birds in an enclosed aviary should be considered. Clearly, although an AI-infected resident population in zoos presents many problems, optimal solutions, short of complete depopulation, that both protect public health and rare endangered species should be sought. Another management option for the protection of captive collections of endangered bird species is preventive vaccination. This option was used in Dutch zoos during an outbreak of highly pathogenic avian influenza virus (H₇N₇) in poultry in the Netherlands in 2003. When the area of the outbreak threatened to encroach on Dutch zoos, the Dutch Federation of Zoos requested permission from the European Commission for preventive vaccination of zoo birds to avoid pre-emptive culling of valuable and sometimes endangered bird species in their collections. The European Commission granted permission (for details, see European Commission directive^ref) providing that the zoos fulfilled strict conditions. These conditions included collection of blood before and after vaccination, registration of all vaccinated birds, and a specific standstill of vaccinated animals and products of vaccinated animals. Birds in 10 zoos from the Netherlands were vaccinated with an inactivated, adjuvanted H₇N₁ virus vaccine previously used in poultry. The difference in the neuraminidase (N₁ in the vaccine strain instead of N₇ in the field strain) made it possible to distinguish vaccinated birds from infected birds. Of 211 birds in 13 orders tested, 81.5% developed a titre > 40, which is considered protective in chickens. The results of this study suggest that vaccination with a heterologous strain is a useful tool for the protection of birds in zoos against highly pathogenic H₇ virus infection, and is a suitable alternative or additional measure for confinement and pre-emptive culling when implemented together with virological monitoring and strict bio-security measures at zoos. We are aware that the 2003 outbreak of H₇N₇ virus in the Netherlands differs in certain aspects from the ongoing outbreak of H₅N₁ virus in Asia. Despite these differences, we strongly feel that preventive vaccination of bird collections in zoos by use of a high-quality, adjuvanted H₅ virus vaccine should be considered as part of the protective management strategy against H₅N₁virus infection. Definitely, when collections of endangered bird species are involved, this option should not be neglected. HPAI (H₇N₇): vaccination of zoo birds and transmission to non-poultry species. In 2003 an outbreak of HPAI virus (H₇N₇) struck poultry in the Netherlands. A European Commission directive (Commission Decision 2003/291/EC of 25 April 2003) made vaccination of valuable species in zoo collections possible under strict conditions. We determined pre- and post-vaccination antibody titres in 211 birds by haemagglutination inhibition test as a measure of vaccine efficacy. After booster vaccination, 81.5 per cent of vaccinated birds developed a titre of 40, while overall geometric mean titre (GMT) was 190 (IC₉₅ : 144-251). Birds of the orders Anseriformes, Galliformes and Phoenicopteriformes showed higher GMT and larger percentages developed titres 40 than those of the other orders. Antibody response decreased with increasing mean body weight in birds 1.5 kg body weight. In the vicinity of the outbreak, H₇N₇ was detected by RT-PCR in wild species (mallards and mute swans) kept in captivity together with infected poultry, illustrating the potential threat of transmission from poultry into other avian species, and the importance of protecting valuable avian species by means of vaccination^ref. The situation in Jakarta is different from the Netherlands in some significant respects. Foremost is the propensity of this H₅N₁ to cause human deaths and that Jakarta itself has been declared an "extraordinary case region". Nevertheless, the vaccination strategy detailed above does appear to have several advantages when combined with strict biosecurity. First, it can differentiate between vaccinated birds and H₅N₁-infected birds. Secondly, if the protection levels are adequate in the captive birds, zoo keepers and other personnel would have enhanced protection against being infected. Finally, vaccination as one tool in a comprehensive strategy might allow for the preservation of very rare or endangered species until H₅N₁ can be controlled and possibly eliminated from Jakarta. For any Pacific Island Country or Territory which has a rare bird collection, it might be prudent to consider a contingency plan for these collections of birds. Closure of the facility to the public may be wise during any outbreak or suspected outbreak to minimise the risk of contact with infected material. Improved biosecurity of the facility to minimise direct or indirect contact with wild birds would also reduce the chances of infection. Vaccination may be another strategy worthy of consideration, and here the vaccine of choice would probably be an oil adjuvant killed H₅N₂ vaccine, which is currently available commercially and is heterologous to the current H₅N₁ strain affecting SE Asia for purposes of DIVA. Different species of bird are known to respond to this kind of vaccine, but there are some data from the Netherlands and Singapore on this. The Pacific Community is 22 islands and territories ranging from the
Northern Marianas to Pitcairn Island, with a population of about 7 million. Some places are rapidly increasing in population and others are decreasing. The members of the Pacific Community are spread over 30 million km², > 98% of which consists of ocean; the Pacific region is vast. Of its 7500 islands, only about 500 are inhabited. The islands themselves feature great geographical diversity. Papua New Guinea accounts for 83% of the land area, while Nauru, Pitcairn, Tokelau, and Tuvalu are each < 30 km^2ref.
Nearly 85 people are being treated for suspected bird flu from at least 9 provinces out of 33 in the country (with Jakarta having the highest case number of 28) but only 10 patients have tested positive: of the total, 20 patients were under observation at Jakarta's Sulianti Saroso hospital for infectious diseases :
• children :
• a 1-year old girl was admitted on Sep 24
• a 2-years old girl died at Jakarta's Christian PGI Hospital after suffering a high fever and respiratory problems : no results have yet been announced
• a 2-year-old infant would be able to leave the hospital once a clearance was obtained from the Health Ministry
• a 3 year old child
• a 4-year old boy from Lampung province on Sumatra
• a 5-year old girl was transferred from a private Jakarta hospital on Sep 20 and died on Sep 21 : on Sep 23 tests carried out in Indonesia showed she did not have the virus. Indonesia was not planning to send her blood samples to a laboratory in Hong Kong for confirmation
• a 5-year-old girl tested positive in Indonesia. By WHO standards, however, the final proof rests on the outcome of a PCR test, which in the girl's case showed negative (?)

a 5-year-old boy from Wonogondo village, Kebonagung subdistrict, Madiun, East Java, was rushed to Dr Soedono Hospital on Fri Sep 30 night after being treated at the Pacitan Regional Hospital since Thu. The boy's mother said her son got bird flu symptoms after 15 of her chickens were found dead suddenly. The boy is the 2nd suspected avian influenza case in East Java.
• a 6-year old-girl
• a 7 year old boy
• an 8 (9?)-year-old boy (Firdaus), nephew of the 27-yrs old Jakarta woman who died of bird flu on Sep 16, was hospitalized on Sep 17 has been confirmed to have H₅N₁ virus by a WHO reference laboratory in Hong Kong. The boy remains in hospital for observation and treatment. He didn't live with her, but had contact with his aunt after she became ill. Onset of his symptoms occurred four days after she became sick. It's possible that there's a common source of infection, but given the timing, we can't rule out human-to-human transmission^ref
• a 20-month-old baby who was suspected of developing bird flu symptoms finally died on Wed Oct 5 after 3 days of intensive treatment at the Sulianti Saroso Hospital in Jakarta due to respiratory problems and worsening pneumonia
• adults :
• a 27-year-old woman from Jakarta developed symptoms on 17 Sep 2005, was hospitalized in Jakarta on 19 Sep 2005, and died on Mon 26 Sep 2005. It was unclear how the woman got the disease, but she had been in contact with 15 diseased and dying chickens in her household shortly before the onset of illness. Tests done in Indonesia on Her saliva and blood were positive for bird flu both in local tests and in confirmatory testing conducted at a WHO reference laboratory in Hong Kong^ref
• a 23-year-old man (Slamet Wibowo) resident of Bogor, West Java, was referred on late Tue Sep 27 Sulianti Saroso from a private hospital in Cibinong, registered positive for the bird flu virus at RT-PCR in both clinical and blood tests shortly and died on Sep 30. He had had direct contact with birds and poultry as he bred birds and many of his neighbours raised chickens
• a 30-year-old housewife died during intensive hospital treatment for developing bird flu symptoms
• SP, a woman from Ponggok village, Kota sub district, Pacitan district is currently under intensive treatment at the Dr Soetomo Hospital here for suspected AI
• a critically ill 68-year-old man suspected of having contracted AI died on Sun 2 Oct 2005 after being treated in hospital for less than a week. The patient died at the Sulianti Saroso Hospital for infectious diseases after being admitted on 30 Sep 2005. He owned a chicken farm in Bogor. 2 tests had produced negative results
• a 21-year old man from the province of Lampung on the island of Sumatra developed symptoms on 20 Sep 2005, was hospitalized on 24 Sep at the Abdul Moeloek general hospital in Lampung, tested positive at RT-PCR on Oct 6 2005, and fully recovered. Initial investigation has revealed that the man had direct exposure to diseased and dying chickens in his household shortly before the onset of illness.
• his 4 year old nephew developed symptoms on 4 Oct 2005, was hospitalized, was found positive to H₅N₁ avian influenza virus in Hong Kong, recovered fully, and has returned home
• his 5-year-old boy developed symptoms in October 2005 and fully recovered. Both the child and his brother had direct exposure to diseased chickens during slaughtering. As initial diagnostic tests produced inconclusive results, retrospective confirmation of the child's infection relied on antibody levels in acute blood samples taken during his illness and convalescent samples taken following recovery. He tested positive on Feb 5^{ref1, ref2}
• a man died on Oct 11 after just a few hours at Sulianti Saroso hospital. The man showed symptoms of bird flu but the results of tests were not yet available
11 of 22 patients had been to Jakarta's Ragunan zoo before birds fell ill :
• 3 workers : of the 500 zoo employees, 143 have been identified as being at high risk for exposure to the virus
• a 28 year old guide
• a 39 year old vendor
• a food worker was hospitalized on Sep 19
• a 9 year old girl
... suspected of contracting the disease were being treated the Sulianti Saroso infectious diseases Hospital in north Jakarta : 2 are suspected of having the symptoms of bird flu based on the lab tests. The other one is still under observation. Blood samples from the 3 have been sent to Hong Kong for testing : the 3 children - 2 of whom were in serious condition in the hospital's intensive care unit - are not believed to have contracted the virus from the zoo. 5 out of 22 people who had been admitted to the hospital were allowed to go home because they had been found not to have the disease
• a boy who died in East Kalimantan province on Borneo island in the 3rd week of Sep had bird flu symptoms. Officials have not said if he was tested for the virus.
The Indonesian government has been hoping to attract 6 million foreign tourists in 2005, which would generate USD 5.8 billion in foreign exchange from the industry -- higher than last year's 5.3 million tourists and USD 5 billion in revenues. The number of foreign arrivals during the year's 1st 7 months was 2.45 million, according to the Central Statistics Agency, down 4.08 per cent from the same period in 2004. Indonesia's tourism sector has been in the doldrums since the Bali bombings in 2002, and terror attacks on the JW Marriott Hotel and the Australian Embassy, both in South Jakarta, the following years, scared off potential tourists. At the same time, a series of SARS and influenza epidemics in the region, as well as the 26 Dec 2005 tsunami, made things worse for the sector. The occupancy rates of hotels in the country dropped from an average of 55% to 30% during the SARS outbreak.
The virus has spread to 22 provinces out of 33 in the Indonesian archipelago, killing > 9.5 million domesticated birds since 2003.
On October 2005 Indonesian health authorities found chickens which tested positive for the H₅N₁ bird flu virus but which appear to be healthy instead of dying within 24 hours of contracting it, a sign that the bug may become harder to detect.  In case the test was a serological one, there could have been various reasons for the lack of clinical symptoms: a low-pathogenic virus, natural resistance of the birds, or their immunity. Such an immunity could have been established also by a heterologous H₅ virus, either a wild one or a vaccine strain (mass vaccinations are reportedly being carried out in Indonesia). Obviously, background epidemiological details, as well as data on the virus itself, are necessary before an evaluation of the Indonesian H₅N₁ virus strain and hypotheses on public-health implications can be made. It would help if such information were obtained directly from Indonesia.
Some testing conducted in Java in 2004 showed the vaccine's protection level was only about 11.8 to 28% : local producers intentionally lowered the vaccine quality to make more profits from the contract. Farmers across the country had also complained they had not received compensation for culling flocks because officials had embezzled the money. According to the last follow-up report of Indonesia to theOIE, dated 2 Aug 2005, there had not been any outbreaks ofavian influenza with clinical signs in Tangerang district --where fatal cases in humans were reported -- since April 2005. It will be interesting to note whether the current reported suspicion, related to deficient poultry vaccines, is based upon clinical observations. One might wonder whether the suspicions are related to last week's information on the Indonesian health authorities' discovery of asymptomatic chickens which tested positive for the H₅N₁ bird flu virus. One of the suggested explanations to this finding was immunity of the tested chickens to H₅N₁, conferred by an heterologous H₅ virus (vaccine strain ?!).
On Oct 20 2005 a 63-years old man and his 22-years old son in Jakarta were suspected to be the 3rd cluster of related people suspected of having contracted the bird flu virus, but on Oct 21 laboratory testing in Jakarta has not confirmed the initial clinical diagnosis and at present these cases are not ranked as avian influenza cases. Also a baby not related to the father and son was admitted to Jakarta hospital with suspected bird flu on the same day.
> 25 previously healthy backyard chickens dropped dead since Oct 21 to Oct 26 2005 on the resort island of Bali. According to Indonesia's official reports to the OIE, the last outbreak of clinical HPAI in avians occurred in Indonesia on 4 May 2005, in the village Ujung Padang, Sumatra Utara (Follow-up report No 9 of 27 Jun 2005^ref. Though human cases have been reported later, only serological findings from asymptomatic avians have been reported in the last available follow-up report No 10, dated 2 Aug 2005^ref. In view of the appearance of cases in humans, it is conceivable that cases in avians do occur but remain undetected, underlining the need for enhanced surveillance and reporting.
• on Nov 5 it was confirmed that a 19-years old woman from the town of Tangerang, near the capital Jakarta, developed symptoms on 19 Oct 2005, was admitted to the hospital on 26 Oct 2005 and died on 28 Oct 2005 had bird flu, bringing the total deaths from the disease in the world's fourth most populous country to 5. One of the nurses who tended to the woman who died was admitted to Sulianti Saroso hospital for infectious disease in north Jakarta just before midnight on Thu Nov 3 after complaining of bird flu-like symptoms and is now in an isolation ward in Jakarta. The infectious diseases hospital has also been treating the deceased woman's daughter and 2 of her nephews, all under 5 years of age, all admitted to the hospital on Tue Nov 1 with bird flu-like symptoms : while all the 3 toddler-age children no longer suffer from high fevers, coughs and respiratory problems, the woman's 8-years old brother (nephew ?) developed symptoms on 25 Oct 2005 and tested positivefor the disease, taking the number of confirmed Indonesian cases to 9. Field investigation has found evidence of sick and dying chickens in the residential area of the 8-year-old. His 19-year-old sister is known to have visited this area.. Tests on the other 2 children came back negative.  If the nurse is confirmed as a human case of avian influenza virus infection, this cluster of cases may be indicative of person-to-person transmission of avian H₅N₁ influenza virus
• a 16-year-old girl from Jakarta developed symptoms on 4 Nov 2005 was admitted to a Jakarta hospital on Sun 6 Nov 2005 suffering from high fever and heavy pneumonia, died on Tue morning 8 Nov 2005, and was confirmed as H₅N₁ on Nov 10. She lived in an East Jakarta suburb near a bird market and had chickens and pet birds in her house, but no evidence of direct contact with infected fowl has yet been established.
• a 20-year-old woman from Jakarta developed symptoms on 5 Nov, was hospitalized on 9 Nov, and died late on Sat 12 Nov 2005 in Jakarta's Infectious Diseases Hospital^ref.
• a 16 year old youth was admitted to the Sulianti Saroso Hospital on 11 Nov 2005 in intensive care and tested positive for H₅N₁ on 15 Nov 2005
• a 13 year old girl died on 13 Nov 2005 : an initial local test on the girl had proven negative for bird flu. However, it was reported later by Reuters that shehad tested positive for H₅N₁ virus infection by laboratory test carried out locally^ref. The results of confirmatory tests from Hong Kong were awaited.
• a ?-years old man from Central Java province was admitted on 25 Nov 2005, recovered and his samples tested positive for H₅N₁ at a WHO-recognized laboratory in Hong Kong on 15 Nov 2005^ref. Is he the same as 46-years old father-of-two Darmanto, hospitalized with 105°F fever, and transferred Dr. Moewardi Hospital in nearby Solo. Though he continued to lose weight - 30 pounds in two weeks - and X-rays of his lungs showed the rapid spread of the virus, he eventually recovered, thanks in part to the anti-viral drug Tamiflu. When Darmanto returned to Muntilan, his village 260 miles southeast of the capital Jakarta, in December he was hurting financially and eager to resume his job as a tailor^ref.
• a 16-year-old boy from Bandung, West Java Province, probably had contact with infected chickens, developed symptoms of fever and cough on 6 Nov 2005, followed by breathing difficulties a few days later, was admitted at a hospital in Bandung on 15 Nov 2005. tested positive for H₅N₁ on 25 Nov 2005 and remains in stable condition : his 2 brothers, aged 7 and 20 years, had onset of illness on 3 Nov 2005 and died on 11 Nov, 5 days before his hospitalization, following symptoms of fever and breathing difficulty. The presumptive diagnosis was typhoid fever. No samples were taken before burial, which precludes definitive diagnosis. WHO reports laboratory-confirmed cases only. No other cases of influenza-like illness were detected in the 80 households of the village. The field investigation found that chickens in the family household had died during the 2 weeks preceding onset of illness in the deceased brothers. Samples from animals have been collected for testing and the investigation continues^ref.
• a 25-year-old woman from Tangerang (west of Jakarta) had contact with dead chickens around her house, developed symptoms of fever and stomach discomfort on 17 Nov 2005, followed by cough and breathing difficulty. She was admitted to hospital on 23 Nov 2005, died on 25 Nov 2005 at Jakarta's main hospital for bird flu patients and tested positive for H₅N₁^ref
• a 35-year-old man developed symptoms of fever, cough, and breathing difficulty on 6 Nov 2005, was hospitalized at the private Pantai Indah Kapuk hospital in North Jakarta on 9 Nov 2005, died on 19 Nov 2005 and tested positive for H₅N₁ on Dec 13. The latest victim lived in a residential areas in the capital, West Jakarta : he was building his house and had contact with free-ranging chickens that carried the virus. Doctors had initially planned to transfer the patient to the avian influenza treatment center at the Sulianti Saroso Hospital, but were unable to move him due to his critical condition. Family members and close contacts were placed under observation and tested for possible infection. No evidence of additional cases has been detected^ref
• an 8-month-old baby may have caught the disease from an infected pigeon and was put into an isolation ward at the Sulianti Soroso hospital in Jakarta on 6 Dec 2005. 6 other patients are undergoing tests at the hospital
• 5 new suspected avian influenza patients were admitted at Sulianti Saroso Hospital overnight on Mon 12 and Tue 13 Dec 2005 from several areas of Jakarta, which now has a total of 6 patients being treated for suspected avian influenza infections. Some of the 5 new cases were in a worse condition than the 6th patient, a 23 year old woman, who has been in intensive care for the past few days.
• a 39-year-old man from East Jakarta first reported symptoms of fever, headache, cough, shortness of breath, and rapidly progressive leukopenia on 9 Dec 2005. He was hospitalized on 11 Dec 2005 and died on 12 Dec 2005. He tested positive for H₅N₁ on Dec 19. Family members and close contacts were placed under observation. Investigations are being undertaken to determine the source of the man's exposure. While he did not keep poultry in his household, chickens and other birds were found in his neighbourhood. Samples from these birds have been taken and are undergoing tests to determine whether they may have been the source of infection^ref
• an 8-year-old boy from the Utan Kayu area on the east side of Jakarta developed symptoms of fever and cough on 8 Dec 2005. He was

hospitalized on 13 Dec 2005, died on 15 Dec 2005 at a private Muslim hospital in Jakarta and tested positive for H₅N₁ on Dec19. Family members and close contacts were placed under observation and tested for possible infection; however, none have developed symptoms. Investigations have been undertaken to determine the source of the boy's exposure and samples from pigeons around his household are being tested^ref.
• a 48-year-old man was admitted to the Tidar General Hospital in the Central Java town of Magelang suffering high fever and respiratory problems and died after 10 hours of treatment on Dec 31 2005, but tested negative on Jan 2
• a 39-year-old man from Tangerang in Banten province, a town south-west of Jakarta where there have been bird flu outbreaks, died on Mon Jan 2 2005 after being treated for a day at Jakarta's Sulianti Saroso hospital. Tested positive for H₅N₁ locally on 11 Jan
• a 29-year-old woman  a 29-year-old woman who worked as a midwife at the maternity ward in a Jakarta hospital. She developed pneumonia-like symptoms on 31 Dec 2005, was admitted to Jakarta's Sulianto Saroso hospital on 2 Jan 2006, and died on 11 Jan 2006. She tested positive locally on 11 Jan and in Hong Kong on 14 Jan. Investigations conducted by the Ministry of Health and WHO found evidence of poultry deaths in her neighbourhood in the 2 weeks prior to onset of illness. Other findings indicate that the patient visited a live bird market to select and purchase freshly slaughtered chicken in the days immediately prior to symptom onset. Investigations at these sites are continuing. The possibility that the patient acquired her infection from an occupational exposure is considered unlikely. Investigations conducted today reveal that none of her co-workers was ill prior to the start of her illness. According to hospital records, no patients in the ward where she worked showed signs of influenza-like illness while hospitalized. Contact tracing has been extensive for this case, as the woman worked 2 shifts at the hospital at the time of symptom onset. At this stage, there is no evidence that she transmitted the infection to any patients under her care or to colleagues at the hospital. Similarly, there are no signs of illness in family members or neighbours. Health monitoring of contacts will continue until the maximum incubation period has ended^ref.
• 3 cases in one family coming from Indramayu, West Java (175 km (110 miles) east of Jakarta). They killed and ate infected birds on Jan 4 : they all tested positive for bird flu on Jan 15, 2006^ref :
• a 13-year-old girl (initialed N^ref) developed symptoms on 6 Jan 2006, was hospitalized in Indramayu. The medical staff recommended she be moved to a better hospital, but she died on 12 Jan 2006 as the ambulance was coming to transport her.
• her 4 (3 ?^ref)-year-old brother (initialed E^ref) developed symptoms on 8 Jan 2006, was hospitalized on 14 Jan 2006, and died on 17 Jan 2006
• her 14-year-old sister was next to become ill, with a slight fever, not enough to keep her out of school. But health workers urged that she too be admitted to the hospital in the West Java capital Bandung on 14 Jan 2006 : she recovered and was discharged on Jan 28^ref
• their 43 year-old father began complaining of trouble breathing while overseeing the funeral for another of the children and was hospitalised  in the West Java city of Bandung with suspected AI on 17 Jan 2006 and was discharged on Jan 28^ref
• an 11 year old girl (initialed KH^ref) who lived near the 2 deceased children was hospitalized on Thu 19 Jan 2006
This was Indonesia's 5th cluster of bird flu cases, where people living in close proximity had fallen ill. There was no evidence of human-to-human transmission. Investigations conducted by the Ministry of Health and WHO found evidence of a large poultry outbreak in the family's neighborhood. Chickens kept by the family began to die 3 days before the 1st patient developed symptoms. All family members had close contact with the diseased chickens and assisted in the removal of dead birds. Contacts have been traced; blood samples have been taken, and monitoring for signs of influenza-like illness continues. The authorities began culling operations in the area on 21 Jan 2006. The question of how the mother eluded the virus is part of a puzzle now stumping global influenza experts. Little is known about why some people become ill while others, with even greater exposure to the infection, remain healthy. For instance, thousands of agricultural workers, officials and soldiers have been culling poultry across Asia in an effort to contain the spread of bird flu, at times lacking even basic protection such as gloves, masks and goggles. Yet according to WHO records, not one has fallen sick. This finding has reinforced the suspicion that some people are more susceptible than others. Moreover, even if research proves that some people are more susceptible, this information may have little practical benefit if the virus mutates into a form that spreads faster than people can be tested for genetic risk. Behavior and not genetics might be the determining factor in who in a family gets sick. Could the rest of the family have had more contact with sick chickens than the mother did? That's doubtful because as a rural homemaker she was in daily contact with livestock. Perhaps the 3 children contracted the virus by playing with chickens. Could they have then passed it to their father but not their mother? Relatives said the mother was the parent who usually looked after the children and who carried her ailing son in a sling across her chest for days. When pressed by a reporter, the mother suggested she was spared because she did not eat chicken when the rest of the family feasted on the sick birds. She said she had high blood pressure and avoided meat. But back in the village, next door to the family's home, her mother-in-law dismissed that explanation. "Many people ate that chicken. I ate the chicken," recalled [the mother-in-law], 70, sitting cross-legged on the porch. Beside her in the rain-soaked yard were the abruptly abandoned reminders of her family: her son's rickety meatball pushcart and her grandson's plastic tricycle. "The rest of us didn't get sick," she continued, eyes reddening. "So that can't be the reason". On the basis of the predominance of blood relatives (22 clusters involving siblings, parent and child, children and grandfather, or niece and aunt -- rather than only 3 clusters involving husband and wife)  -- among those infected in so-called "clusters" of avian influenza virus infection, it is reasonable to suggest that genetic constitution may play a role in the susceptibility and resistance of individuals to infection. However, the numbers are small and other factors such as age, nature of exposure, and behavior cannot be discounted. A compounding factor is that there is little published information on the immune status of the population in the affected communities. The observation that none of those employed in commercial poultry operations and in the culling of diseased fowl have been victims of H₅N₁ avian influenza may indicate that asymptomatic infection and development of immunity is widespread. Also the predominance of children and younger people among the victims of infection could indicate protection of older people by development of immune responses. Comprehensive data on seroprevalence are still lacking^ref. Perhaps childhood exposure to a weaker form of H₅N₁ (or H₉N₂) would confer immunity on one spouse and not the other.  It would be interesting if this apparent immunity of one spouse only occurs when the husband and wife grew up far apart -- in separate towns or villages.
• a 22-year-old man, a banana vendor at a traditional market in East Jakarta where poultry meat was sold, was admitted to hospital, tested positive for H₅N₁ according to local test results on Wed 25 Jan 2006, died at 2 p.m on 26 Jan 2006^ref, and definitevely tested positive for H₅N₁ on Feb 5^{ref1, ref2}. Neighbors near his home reported poultry deaths prior to his onset of symptoms
• a 15-year-old boy (identified only as "Y") from Padalarang developed a high fever since Sat Jan 28 and over-the-counter drugs did not help. The boy was then taken to Mitra Kasih Hospital in Cimahi, which referred him to Hasan Sadikin Hospital in the West Java city of Bandung, where he was admitted with a high fever and in severe respiratory distress on Mon Jan 30. Although he received oseltamivir^ref and was placed on a ventilator, he died on Wed Feb 1 morning and tested positive for H₅N₁ on Feb 4^ref. His father, Sriyono, said some 20 chickens began to die about 10 days ago just 10 meters from the boy's house^{ref1, ref2}
• a 9-year-old girl from around the town of Indramayu in West Java province was hospitalized on 19 Jan 2006, tested positivefor H₅N₁ on Feb 4, and has since fully recovered. She lived in a village neighboring that of the 2 fatal cases in siblings confirmed on 23 Jan 2006. The girl was unrelated to them. Investigation of these cases resulted in the girl's prompt hospitalization and treatment. Poultry deaths were reported in her village prior to symptom onset^{ref1, ref2}
• a 38-year-old woman died in West Java on Feb 4. Local tests found the woman had H₅N₁ infection, but samples were being sent to the WHO-affiliated laboratory in Hong Kong for confirmation^ref
• a 22-year-old woman from Bekasi developed symptoms on 25 Jan 2006, was treated at Mitra Keluarga Hospital since Jan. 30 for a high fever, was transferred to Sulianti Saroso infectious diseases hospital on Feb. 4, tested positive for H₅N₁ locally on Feb 7 and died on Feb 10^ref. Some reports affirmed no poultry or caged birds near her house^ref, but WHO reported Her neighbors kept chickens and samples from these chickens and from pet birds in a market near the woman's home are being tested by Indonesia's animal health authorities^ref
• her 8-year-old brother was being treated in an isolation room at Sulianti Saroso on Mon Feb 6
• a 27-year-old woman from Bekasi (unrelated to the other) developed symptoms on 31 Jan 2006, was treated in the designed bird flu hospital of Sulianti Suroso in eastern of Jakarta and tested positive for H₅N₁ locally on Feb 8^ref and died on Feb 10^ref. Deaths of chickens in her neighborhood were reported 4 days prior to symptom onset^{ref1, ref2}
• a 23-year-old man (named Purnomo) working in a traditional market in East Jakarta transporting chicken eggs that might have had droppings on them developed symptoms on 5 Feb 2006, was hospitalized on 7 Feb 2006, died on Fri 10 Feb 2006 in a Jakarta hospital and tested positive for H₅N₁ on Feb 14 and at CDC on Feb 18 . None of the contacts traced showed influenza-like illness^{ref1, ref2, ref3}
• 4 members of a family which lives about 100 miles east of Jakarta in the village of Cipedung in west Java province, in the modest dwelling of a meatball peddler, with dirt floors, flimsy bamboo walls and a ramshackle roof that leaks in the rain, had contact with chickens, were treated in a hospital for symptoms of the virus and are under observation^ref. Chickens often wandered inside, sleeping beneath the platform beds. Health investigators have attributed the outbreak to infected poultry.
• the country's suspected 6th cluster of human infections, involving 2 adults and their 2-year-old daughter^{ref1, ref2}
• a 27-year-old woman (Yulia Gino) from East Jakarta developed symptoms on 13 Feb 2006 and died on Mon Feb 20 and tested positive for H₅N₁ at CDC, Atlanta, on Feb 25. Investigations carried out by local authorities found reports of chicken deaths in the woman's neighborhood 4 days prior to her onset of symptoms^{ref1, ref2}
• a 13 (12?)-year-old girl (Hanif Cahaya Fitri) from Jurug (Karangkidul^ref) village in Andong subdistrict, Boyolali regency of Central Java province was suspected of having bird flu, was hospitalized for 9 days at Moewardi hospital in Surakarta and died on Wed Mar 1 night^ref. Her body has been sent to her hometown in Boyolali, Central Java, for burial : blood tests for the victim have been sent to a Jakarta laboratory for confirmation^ref. Her younger brother, 10-year old Nandya Kurniawan, died on Tue Feb 28 at a local hospital in their home town of Boyolali south of Solo. Both children had been in contact with sick chicken as they live near a farm^ref. A neighbour was also hospitalized^ref
• a 31-year-old man (identified as Daryoto) with bird flu symptoms is being treated at Moewardi hospital in Solo^ref. The patient also used to live near large-scale quail breeding centers : he was believed to have been infected by the carcasses of dead birds, which had been dumped in the area during the past month. "Thousands of quail died every day and their remains were just thrown away into a nearby river," the man's wife said.Clinical symptoms, including coughing and a high fever, indicate that he is bird flu-positive^ref
• 2 more patients suspected of having bird flu died, one at Tidar hospital in Magelang and the other at Dr. Kariadi hospital in Semarang^ref
• a 12 year old patient from Singkil village, Ponorogo, who is believed to be infected with the virus, remained serious on Thu 2 Mar 2006 in Madiun, East Java. A sample of the patient's blood has been sent to Jakarta for testing and the results would be available within a week^ref
• a 7 year old boy was admitted to the intensive care unit at the Saiful Anwar Hospital in Malang, with suspected avian influenza symptoms. The boy, who had earlier been treated at the Muhammad Saleh Hospital in Probolinggo, was still under observation to determine his illness^ref
• a 20-year-old and a 12-month-old were admitted separately in the early hours of Wed 1 Mar 2006, both after the hospitals where they were being treated suspected AI. 7 other patients were also being treated as suspected cases at the hospital, after local tests cleared 2 more patients who were to be discharged^ref. Another confirmed bird flu patient from Magelang, has already been discharged from Moewardi hospital in Surakarta where he was treated. A second patient, a resident of Klaten, is still being treated at Moewardi hospital in Surakarta. His condition is reported to be improving.
• a 3-year-old boy from Indonesia's Central Java province who had been in contact with fowl died of bird flu on Mar 2-3, 2006^ref
• a 4-year-old boy (Wahyu Kurniawan) had contact with chickens that had died near his home, developed symptoms on Feb 10 and died on Feb 28 at Karyadi hospital in Semarang (7° South and 110°24' East), central Java, and tested positive for H₅N₁ on Mar 10^{ref1, ref2}
• a 4-year-old boy died on Mon Mar 6 at Sayidiman hospital at Magetan in East Java less than 10 minutes after arriving^ref
• a 12-year-old girl (Hanif) from Boyolali (approximately 7°30' South and 110°30' East) in Central Java, developed symptoms (fever) on 19 Feb 2006, was hospitalized on 23 Feb, died of bird flu on Mar 1 in Solo and tested positive for H₅N₁ on Mar 10^{ref1, ref2}. Chickens in her household died in the days preceding symptom onset : the girl's 10-year-old brother also fell ill on 19 Feb and died on 28 Feb 2006. As his symptoms were compatible with a clinical diagnosis of dengue haemorrhagic fever, no testing for H₅N₁ was carried out. It will therefore never be known whether he may have died following co-infection with dengue and H₅N₁ avian influenza. A local investigation was conducted and no additional cases or symptomatic contacts were found. Rapid tests detected the H₅ virus subtype in chickens from the children's household^ref
• in Bandung, the number of suspected bird flu patients rose by 11 to 66 as of Wed 1 Mar 2006. The latest patient was admitted to the city's Hasan Sadikin Hospital on Wednesday^ref
• the recent deaths of a pregnant mother and 2 children tested negative for H₅N₁ locally on Wed 8 Mar 2006^ref
• a 25-year-old, 22 weeks pregnant woman (Yani Mulyani) who lived with her family in Tanah Abang, Central Jakarta, was treated for 2 days at Budi Kemulian Hospital before being transferred on March 1 to Sulianti Saroso Hospital with fever and respiratory problems. She received a blood transfusion and assisting her with breathing aids, but she died after 6 a.m. on Mon 6 Mar^{ref1, ref2}. The woman's unborn baby also died^ref, but she tested negative for H₅N₁ locally on Wed 8 Mar 2006^ref
• a 10-year old boy from Andong subdistrict, Boyolali district (as the 2 previousy confirmed cases) in Central Java died with suspected bird flu on Sat Mar 4 in Solo^ref
• a 5-year-old boy and a woman in her fifties were admitted on Mar 8 to the Sayidiman Hospital in the East Java town of Magetan with suspected avian flu^ref
• a 15-year-old boy was transferred to Jakarta's Sulianti Saroso hospital on Mar 8 after being treated for one day in a hospital in Cianjur, West Java, southeast of the capital city. Clinical symptoms indicate he could be suffering from bird flu : dead pigeons and chickens found have been found in his neighborhood, but there is no connection yet with the patient^ref
• a 1-year-old girl from west Jakarta died on Thu 24 Mar 2006, shortly after coming into a Jakarta hospital emergency room^ref and tested positive by WHO on Mar 31^ref
• a child under 5 years old who was referred by the Magetan General Hospital to the Dr Soedono General Hospital in Madiun^ref, East Java to the west of Surabaya, with symptoms compatible with bird flu : the patient was accepted at the hospital at around 10:55 pm on Mon 27 Mar 2006 and died at 1:55 am on Tue 28 Mar 2006^ref
• a 23 year old man employed as a poultry worker in West Java developed symptoms on 20 Mar 2006, tested positive locally on 31 Mar 2006^ref and fully recovered on Apr 12. Poultry deaths occurred in the 2 weeks preceding his visit to a farm^ref
• a 20-month-old girl who resided in Kapuk, West Jakarta, developed symptoms of fever and cough on 17 Mar 2006, was hospitalized on 22 Mar, and died on 23 Mar 2006^ref : she tested positive for  on Apr 4. Field investigation found a history of deaths in a chicken flock near her home about one week prior to symptom onset. Chicken deaths in the neighbourhood have continued, but the cause has not yet been identified. Family members and neighbours have been placed under observation and samples from these people have been taken for testing. Preliminary results are negative, but follow-up investigation is continuing^ref
• a 23-year-old man working at a chicken farm in West Java became sick and is still hospitalised at Jamil hospital in Padang, West Sumatra, was confirmed to have bird flu on Tue 11 Apr 2006^ref
• a 24-year-old man from Tangerang, near Greater Jakarta, developed symptoms on 29 Mar 2006, was hospitalized on 5 Apr 2006, and died on 8 Apr 2006^ref
• a family of 5 was admitted to Abdul Moeloek hospital in Bandurlampung on Sun 16 Apr 2006, all suffering from suspected avian influenza. The family -- the husband and his wife, both 52, and 3 of their 6 children, 12, 8 and 5 -- are now being treated in an isolation room. The 5 have all had a high fever and a cough, symptoms of avian influenza. The wife has been treated at the hospital since Thu 13 Apr 2006. Her other 3 children had been diagnosed with bird flu earlier. The 1st one, 15, died 31 Mar 2006, and the 2nd one, 19, died 4 Apr 2006, while the 3rd one, 26, is still being treated at the hospital. Both deceased children died at home before they could be sent to the hospital. Their parents had limited funds and knew little about the virus. Laboratory tests on drug samples taken from the patients confirmed 4 of the children were infected with avian influenza virus, while the remaining 2 were negative, according to data from the Lampung health office. In 2004, at least 1.83 million hens in 9 regencies throughout Lampung province died, possibly from bird flu, and in 2005 the virus killed another 4305 hens in the province. 7 other suspected bird flu patients had been admitted to Abdul Moeloek hospital before the family. After appropriate medical treatment, all recovered^ref. The Ministry of Health may report more fully, but in brief, the full investigation has ruled out H₅ as a cause of illness in this cluster in Lampung. Epidemiological data also did not support an H₅ etiology. Other diagnoses for this cluster appear far more likely^ref.
• a 30 year old man from greater Jakarta who had a history of contact with sick chickens near his house in Tangerang developed symptoms on 17 Apr 2006, was hospitalized on 21 Apr 2006, and died on 26 Apr 2006^{ref1, ref2}
• a cluster of 7 cases^{ref1, ref2, ref3}, all from a family -- which raised a small number of pigs and had chickens, ducks and geese in the neighborhood --  in Kubu Simbelang village in Tanah Karo regency in North Sumatra, fell ill after eating chicken together in a family gathering barbecue on 29 Apr 2006, when they ate pork and chicken. > 15 people attended the barbecue, but there were no signs of any spread beyond this cluster of 7^ref (linked to contaminated fertilizer ?^ref : blood samples from all kinds of animals from an unspecified number of chickens, 4 ducks, 4 geese, birds, cats and dogs turned out negative. 10 out of 11 pigs were initially positive^ref, but on May 19 swab tests from the pigs' nose by the Bogor animal research centre came up negative for H₅N₁ virus^{ref1, ref2}. Manure was also been checked. The result is negative^ref)^ref. The villagers are Christian, and some initially blamed the government of Muslim-majority Indonesia for the deaths and declined to cooperate with health workers^ref
• 7 from a family : family members resided in 4 households, 3 of which were next-door neighbours in the village of Kubu Simbelang, Karo District, North Sumatra. The 4th household was located about 10 kilometres away in the nearby village of Kabanjahe. 3 of the confirmed cases spent the night of 29 Apr 2006 in a small room together with the initial case at a time when she was symptomatic and coughing frequently. These cases include the woman's 2 sons and a 2nd brother, aged 25 years, who is the sole surviving case among infected members of this family. Other infected family members lived in adjacent homes. Full genetic sequencing of 2 viruses isolated from cases in this cluster has been completed by WHO H5 reference laboratories in Hong Kong and the USA. Sequencing of all 8 gene segments found no evidence of genetic reassortment with human or pig influenza viruses and no evidence of significant mutations. The viruses showed no mutations associated with resistance to the neuraminidase inhibitors, including oseltamivir^{ref1, ref2}
• a 37-year-old woman selling fruits and chillies at a market in the village of Tigapanah about 5 km (3 miles) from her home in Kubu Sembelang. Her stand was located about 15 metres away from a stand where live chickens were sold. The investigation uncovered no reports of poultry die-offs in the market^ref. However, the woman kept a small number of backyard chickens, allowed into the house at night. Three of her chickens reportedly died before she became ill^ref. She is also known to have used chicken faeces from these household chickens as fertilizer in her garden. A parallel agricultural investigation has not, to date, detected H₅N₁ virus in PCR tests of approximately 80 samples from poultry, other livestock and domestic pets, and chicken fertilizer taken from the vicinity. The initial case developed symptoms on 24 Apr, was hospitalized on 2 May, and died on 4 May 2006. No samples were collected for testing prior to her burial, but she is considered the initial case in this family cluster as her clinical course was compatible with H₅N₁ infection. The initial case had one sister and 3 brothers. The sister and 2 of the brothers subsequently developed infection. The remaining cases occurred among children in these families. The confirmed cases include 5 males and 2 females with an average age of 19 years (range from 1 to 32 years). Of the 7 confirmed cases, 6 developed symptoms between 3 May and 5 May. These cases include 2 sons of the initial case, her brother from Kabanjahe, her sister, the sister's baby, and the son of a 2nd brother living in an adjacent house. This 2nd brother, the last case in the cluster, developed symptoms on 15 May. Of the 7 cases, 6 were fatal. On the night of 29 Apr, 9 family members spent the night in a small room with the initial case at a time when she was severely ill, prostrate, and coughing heavily. These family members included the initial case and her 3 sons; the brother from Kabanjahe village, his wife, and their 2 children; the 21-year-old daughter of another brother (who did not become infected); and another young male visitor. Following this event, 3 family members -- the woman's 2 sons and the visiting brother from Kabanjahe -- developed symptoms from 5 to 6 days later. The woman's sister, who lived in an adjacent house, developed symptoms at the same time, as did her 18-month-old daughter. Prior to symptom onset, this sister, accompanied by her daughter, provided close personal care of the initial case. The last case in the cluster provided close care for his son throughout his hospital stay, from 9 to 13 May. The son was a frequent visitor in the home of the initial case and was present there on 29 Apr 2006^ref.
• the woman's 2 sons, aged 15 and 17 years, who died on 9 May and 12 May, respectively.
• her 19-years old son (Roy Karokaro) (confirmed) developed symptoms on June 28, was admitted on Mon May 8 and died on Tue May 9^ref
• developed symptoms on May 5^ref
• The 28 year old sister of the initial case fell ill on May 5^ref and died on 10 May (confirmed).
• his aunt, a 29-year-old woman (Anta br Ginting^ref / Anta Beru Ginting^ref) experienced breathing problems and a high fever and died at Adam Malik Hospital on Wed 10 May 2006 5 a.m. She was identified by some local sources as living in Kabanjahe, the capital of the Karo Regency (district), and not in the village where the others lived, but the accuracy of this last statement is not known.
• this sister had an 18 month old daughter (Reneita Boru Ginting)^ref (confirmed) was originally reported as having died after intensive therapy in Adam's central Public Hospital the Owner, Medan, North Sumatra on Friday 12 May^ref, but it was later learned that he did not die until Sunday 14 May. This date of death was confirmed Sunday by I Nyoman Kandun, director general of disease control at the health ministry
• The 5th confirmed case, who is still alive, is the 25 year old brother of the initial case.
• the 6th confirmed case is the 10 year old cousin Ulina Ginting (may be another name for Rafael Ginting (8 or 10), nephew of the initial case (confirmed), who was transferred to RS Elizabeth^ref. He died Sat 13 May, at about 2 p.m. local time, at RS Elizabeth hospital, also in Medan. This may be the individual identified by some news sources as a cousin of the index man, a child aged 8. This also may be the source of reports that 8 members of the family were hospitalized, rather than the 7 for whom we have identification. A statement issued at the end of the 3-day FAO/MOH/WHO closed meeting in Jakarta in June 2006 showed that he had a mutated virus^ref
• his 32-yo father Jones Ginting (uncle of the initial case), who grew limes, chilies and tomatoes, was transferred to RS Elizabeth the same day as his children, received oseltamivir but died on May 22, 2006^{ref1, ref2}. The man helped care for his 10-year-old son at the Adam Malik Hospital in Medan up until the boy's death on 13 May. This would be the first evidence of a 3-person chain of infection. After returning to his home in Kubu Sembelang on May 15, the man began coughing. He was examined on 18 May later by local health-care workers, who observed avian flu-like symptoms. The WHO's Grein recommended on 18 May that he be isolated and treated in the hospital with the Roche Holding AG antiviral drug, Tamiflu. Instead the man fled local health authorities and sought care from a witch doctor. Disease trackers located the sick man late on 21 May in a nearby village. Blood samples and swabs of his nose and throat for viral particles were taken that day and flown to a laboratory in Jakarta. He received oseltamivir but died on May 22 in the arms of his wife in the back of a jeep as he was taken to the hospital after tests confirmed he had H₅N₁, the WHO said on 23 May. Some residents of Kubu Sembelang resented the rapid assessment by some government officials that there was avian flu in the village. "The Minister of Health said that when the family got into the hospital they must be infected with bird flu," Veronita, a food vendor said in an interview on May 17. "The results of the tests hadn't even been reported. Later the Minister of health changed her words and said they `probably' have bird flu." To help instill confidence in the community, "The district leader himself cut off the head of a chicken and had it cooked to prove that the poultry here are safe to eat," Veronita said. Dozens of poultry farmers and sellers from the deceased man's district slaughtered chickens and drank the blood in Medan on 22 May in a demonstration of their frustration at being branded by authorities as having been infected with avian flu. Footage of the protests was broadcast on Trans TV television. The Sumatra experience shows the government and international health authorities need to do a better job educating communities and garnering their trust, said Cheng. The deceased man's wife highlighted the family's suspicion and lack of understanding when she said in a 17 May interview that she believed Tamiflu poisoned her son. Investigators also are following 33 people known to have been in contact with infected family members. Some of the people are taking Tamiflu to prevent the disease. No other suspected cases had been reported^ref. On Jun 16 he was being investigated for rare neurological symptoms associated with the illness^ref
• one additional family member, who had been hospitalized, has subsequently been ruled out based on both negative laboratory results and the absence of clinical symptoms compatible with H₅N₁ infection.
• 3 others from the family were suspected of having H₅N₁, including
• a 40-year-old female (Praise br Ginting; aka Fuji Finting, 40M)) passed away on 4 May 2006 at Elisabeth Hospital
• a 18-year-old man (Bonny Karo-karo / Boni Karakar^ref) died with the same symptoms in A Space of the Longing Isolation, the central Public Hospital (RSUP) Adam the Owner, Street Bungalow, Medan, on Tue May 9, 2006^ref
• 2 nurses who attended to some of the patients fell ill with flu-like symptoms, although she seems to have shown symptoms prior to treating the patients^ref, tested negative on Jun 7^ref : one of the nurses, a 34-year-old woman, experienced only mild symptoms and has subsequently tested negative for H₅N₁ infection. The 2nd nurse, a 42-year-old woman, developed influenza-like illness on 1 June. Test results received today are also negative for H₅N₁ infection^ref.
All 7 victims from the family were related to one another by blood rather than through marriage, reinforcing the suspicions of some influenza specialists that genetic susceptibility could play a role in determining who catches bird flu^ref. 54 surviving family members and other close contacts of cases
have been identified and placed under voluntary home quarantine. All of these people, with the exception of pregnant women and infants, are receiving prophylactic oseltamivir. Public health teams visit these people daily, checking for symptoms. In addition, active house-to-house surveillance for influenza-like illness is being conducted throughout the village, which has around 400 households. A command post for fever surveillance has been functioning in the village since last week. As of Wed 31 May 2006, no new cases suggestive of H₅N₁ infection have been detected since 22 May. This finding is important as it indicates that the virus has not spread beyond the members of this single extended family. No hospital staff involved in the care of patients, in some instances without adequate personal protective equipment, have developed the disease. The last person in the cluster, who developed symptoms on 15 May and died on 22 May, refused hospitalization. He moved between 2 villages while ill, accompanied by his wife. The wife is under surveillance and has not developed symptoms. Despite multiple opportunities for the virus to spread to other family members, health care workers or into the general community, it has not, on present evidence, done so^ref.
Fowl in North Sumatra have been affected by bird flu since July 2005^ref. On 13 May, local media reported panic in the region (but, if there were panic, it likely was in the Karo district rather than in Medan itself). They also reported that the 2 surviving members of the original family were transferred to RS Elizabeth after they attempted to flee the hospital. The accuracy of these reports of attempted flight have not been verified, but it is known that the 2 survivors (not the toddler) were transferred to RS Elizabeth, where one of them died on 13 May. Other sources reported that the 2 were released from hospital, but hospitalized again after their conditions became worse. This last report seems far more unlikely than that they attempted to flee. Both local and international media reported that one or more family members originally contracted the disease from contact with contaminated fertilizer. According to local sources, the family often bought manure from 2 unidentified vendors whose poultry had recently been found positive for the H₅N₁ virus. On 12 May, in addition to reporting 2 deaths (one of which did not happen), local sources also reported that 12 people remained hospitalized in RSUP Adam with suspected bird flu symptoms. It was not stated if these people were other relatives, friends and neighbors, or just what their exact association with them was. These sources also reported that, worried by the spread of the disease, the provincial government of North Sumatra ordered the Karo district health service to sterilize the family's home along with an area of 1 km radius surrounding it. This also means culling or vaccinating all poultry
in that area. WHO officials in Indonesia said Sunday that tests of livestock in the village showed positive results for the H₅N₁ virus and now poultry and swine in the village are being tested. No indication was given if by "livestock" the WHO meant cattle, nor why (if it does mean cattle) these animals were tested before poultry and swine, both of which have stronger indications for infection than do cattle. This outbreak is the largest familial cluster reported in Indonesia to date. It also may be the largest familial cluster ever reported for the H₅N₁ virus and has international health officials worried that the disease may be mutating to become more easily transmitted between humans^ref.
Readers also should be aware of the following language issues with reports coming out of the North Sumatra area: Karokaro is sometimes transliterated as Karakar or as Karo-karo; Beru is sometimes transliterated as Boru, and is often abbreviated as Br.
33 other people in Kubu Sembilang who had contact with the family have been quarantined or have been treated with oseltamivir^ref.
Despite being wild-type for Q226 and G228, the increased levels of H₅N₁ in the nose and throat in patients in north Sumatra may signal the presence of E627K, which allows the H₅N₁ to grow more efficiently at lower temperatures, 33°C (since the body temperature of birds is 41°C and of humans is 37°C)^ref. Thus, the combination of a wild type HA cleavage site, amantadine resistance, and PB2 E627K would be a combination of changes that would be cause for concern. Since none of the above would necessarily be considered significant mutations, they would not be covered in the WHO description of the sequences from the Sumatra cluster. Moreover, Hong Kong's decline to comment on specific questions about these mutations increases the need to make these sequences public immediately^ref. On 23 May 2006, the WHO said genetic sequencing of 2 viruses from the case cluster had shown "no evidence of genetic reassortment with human or pig influenza viruses and no evidence of significant mutations"^ref. A total of 32 mutations were identified in viruses collected from 6 patients in the family case cluster : 21 mutations were identified in a virus from the father of the 10-year-old boy, involving 7 of the virus's 8 genes, suggesting that the virus was evolving rapidly as it spread. In addition, from one to 4 mutations were found in viruses collected from 5 other patients. One of the mutations confers resistance to the antiviral drug amantadine, a finding not reported by the WHO. Viruses from 6 of the 8 cases in the cluster have been sequenced, but the WHO has not shared the findings, saying they belong to Indonesia^{ref1, ref2}.
• a 38-year-old catering businesswoman from Surabaya city in East Java who had dealt with live pigs and pork meat developed symptoms on 2 May, was hospitalized on 7 May, and died on 12 May 2006. The case is the first reported from this area^{ref1, ref2}
• a 12-year-old Indonesian boy from Bekasi in East Jakarta was hospitalized on 7 May and died of bird flu on May 13 2006^{ref1, ref2}
• an 18-year-old East Java shuttlecock maker developed symptoms on 6 May and was hospitalized on 17 May. He is now recovering. The investigation found a history of exposure to dead chickens in his home within the week prior to symptom onset. No further cases of influenza-like illness have been

identified during the investigation and monitoring of his close contacts. Hewas diagnosed with bird flu on Sun 21 May 2006 and confirmed by WHO on May 27^{ref1, ref2}. A sample of his blood will be sent to WHO Hong Kong laboratory for further testing. Authorities are still tracing where the factory got the feathers^ref
• 2 siblings (a 10-year-old girl and a 18-year old boy) from Bandung, West Java province, developed symptoms on 16 May, were admitted to hospital on May 22 and died on Tue 23 May 2006 within hours of each other, and tested positive locally for H₅N₁ on May 25^{ref1, ref2}. Both children had a history of close contact with sick and dying chickens at their home in the week before symptom onset. The identical onset dates strongly suggest that they acquired their infection following a shared exposure to poultry, and not from each other. Follow-up of contacts has not identified further cases of influenza-like illness. The WHO lab in Hong Kong on May 27 confirmed H₅N₁ in the 10-yo girl; the 18-yo boy was considered a borderline case (he tested negative for some procedures), but new tests were positive on May 30^ref3. It may be because of the procedure of specimen collection, handling, maybe the Hong Kong lab had problems^ref.
• a 25-years-old nurse who had never had contact with poultry, developed 39.6°C fever and other flu-like symptoms about 10 days after treating the 2 siblings at Ujungberung Hospital, was isolated at the Hasan Sadikin Hospital on Jun 1^ref and given oseltamivir : she tested negative at Hong Kong WHO lab on Jun 4, was improving and will likely be released this week after finishing the full course of Tamiflu^{ref1, ref2, ref3}
• another nurse who fell ill with flu-like symptoms tested negative on Jun 7. One nurse was shown to be infected with a seasonal

influenza A (H1N1) virus, which is now circulating widely throughout Indonesia. The 2nd nurse experienced only mild and transient symptoms, but was tested urgently as a precautionary measure. Her test results were also negative for H₅N₁ infection^{ref1, ref2}
• a 43-year-old man from South Jakarta developed symptoms on 6 May, tested positive for H₅N₁ at the WHO lab in Hong Kong on May 27, has recovered and been discharged from hospita^{ref1, ref3}
• a 39-years old man from West Jakarta developed symptoms on 9 May, was hospitalized on 16 May, died on 19 May and tested positive for H₅N₁ at the WHO lab in Hong Kong on May 27. The investigation determined that the man cleaned pigeon faeces from blocked roof gutters at his home shortly before symptom onset. No further potential source of exposure was identified^{ref1, ref2, ref3}
• a 15-years old girl from West Sumatra became ill on 17 May and is still in the hospital as May 30^ref
• a 15-year-old boy from Tasikmalaya town in West Java province had contact with infected poultry near his home and his own chickens : the boy's grandfather was a chicken farmer and 40 of his chickens died recently. He developed symptoms on 24 May, was hospitalized on 26 May, was admitted to hospital in Bandung on Mon May 29, died on Tue May 30 and tested positive for H₅N₁^{ref1, ref2}. All chickens will be killed within 1 km of the boy's house^ref. On Thu 1 Jun 2006, workers culled around 1600 chickens in a village in Tasikmalaya^{ref1, ref2}
• a 7-years old girl (named Yohana) from Tangerang district^ref, Banten Province (Pamulang area southwest of Jakarta ?), developed symptoms on 26 May, was hospitalized on 30 May, and late on Thu Jun 1 on the way to Sulianti Saroso hospital after being treated for 2 days in a hospital in South Jakarta and tested positive locally for H₅N₁ on Jun 3^{ref1, ref2}, but negative at the WHO lab in Hong Kong on Jun 7, the first time of a discordant result^ref. The girl's 10-year-old brother Tony died on Tue May 30 in the emergency room before being treated, and the family immediately took him home for burial before samples could be taken from him for testing. The family reported that a number of chickens near their house died before the children went sick. The children's parents and their 2 siblings were taking oseltamivir after suffering similar flu-like symptoms, but they refused to be admitted to a hospital^ref
• a 13 (14?)-year-old boy from south of Jakarta developed symptoms on 9 Jun 2006 one week after helping his grandfather slaughter diseased chickens at the family  home. The boy was hospitalized on 13 Jun 2006, died on 14 Jun 2006, and tested positive for H₅N₁ both locally and at WHO Hong Kong lab on Jun 20^{ref1, ref2}. The grandfather remains healthy. Contact tracing and monitoring are under way to ensure no further cases arise from this exposure setting.
• a 5-year-old boy became ill on 8 Jun 2006, was hospitalized on 14 Jun 2005 and died on 16 Jun 2006 in Tulungagung district, East Java province. A dead chicken was found in a cage 15 m from the boy's home^{ref1, ref2}
• a 3-year-old girl from Cisauk village southwest of Jakarta who had had contact with sick neighbour's chickens became ill on 23 Jun 2006, was hospitalized on 5 Jul 2006 and died on Jul 6, 2006 : she tested positive for H₅N₁ on Jul 14^{ref1, ref2, ref3, ref4}
• a 44-year-old male died on 12 Jul 2006 and tested positive for H₅N₁ on Jul 16^ref
On 24 Nov 2005 outbreaks of bird flu were detected among Arabic (variety of) chickens in 3 districts including Pidie in the northeastern part of Aceh province, where tens of thousands of people still live in crowded refugee camps following the 26 Dec 2005 tsunami (> 130,000 people died in the province and another half million were left homeless). Bird flu has now been found in 23 of Indonesia's 30 provinces.
The US Naval Medical Research Unit No. 2 (NAMRU-2) was set up in Indonesia in 1970 under a bilateral agreement with the USA. But the Indonesian military has been opposed to the centre's presence since the imposition of a US arms embargo in 1999. This followed violence involving the army during Indonesia's withdrawal from the newly independent East Timor. NAMRU-2 has been working with the country's authorities to improve their ability to monitor and diagnose avian flu^ref (see C. G. Beckett et al. Clin. Infect. Dis. 39, 443–449; 2004). Although the centre's original agreement with Indonesia expired on January 2000, until recently the government had turned a blind eye to its continued operation. But on 23 Nov 2005, Indonesia's health ministry posted a memo on its website addressed to all health agencies and hospitals, dated 25 October, stating that "all NAMRU-2 activities must end by 31 December 2005", and not be restarted without a new formal agreement. The US health secretary Michael Leavitt visited NAMRU-2 in mid-October to bolster belated US efforts to build an international coalition against avian flu. He visited NAMRU-2, and promised it US$10 million in extra funding. That the health ministry's memo should appear following Leavitt's visit points to internal government power-play, says one scientist, adding that on 16 November they had been privately assured by Dino Djalal, one of the Indonesian president's chief advisers, that the centre would be allowed to continue. "If this is my government's policy then they must have their reasons," says Sardikin Giriputro, deputy director of the Sulianti Saroso Infectious Disease Hospital in Jakarta, which treats most of the country's avian flu victims. "I have enjoyed a lot of benefits and cooperation with NAMRU-2 — it would be a great pity if its activities were stopped"^ref. On Dec 23, 2005, following talks between Namru-2 and the health ministry, however, the government is to assess the centre's research projects on a case-by-case basis, and may grant them extensions to continue beyond the 31 December deadline, pending negotiation by the US and Indonesian governments of a new agreement on the centre's future.
Over the Dec 18-19, 2005 weekend the government expected to vaccinate 47 million people who have direct contact with poultry and birds across the country against regular human influenza. This would reduce the opportunity for H₅N₁ to interact by genetic reassortment with the ordinary human flu virus and becomes easily transmissible. The cost of the vaccination drive, however, is estimated at Rp 5 trillion (nearly US$500 million), which the state budget cannot afford.
According to Indonesia's last report to the OIE, sent on 6 Jan 2006, the following main regions had been affected by avian influenza: Nanggroe Aceh Darussalam; Bali Badung; Jakarta South; Jambi Sarolangun; West Jawa; Central Jawa; Lampung Bandar; West Lampung; Lampung Tangamus; Lampung Tulang; Riau Dumai; South Sulawesi; South-east Sulawesi; West Sulawesi; South Selatan; North Sumatra; Yogyakarta.
> 21,000 chickens have died in Indramayu, Sukabumi, Subang, Cirebon regencies and Ciberon municipality, West Java since Dec 2005 to Feb 2006^ref
As of Feb 5, 2006, Indonesia is still awaiting the result of WHO tests on 11 other probable cases, 4 of them fatal, tested positive locally^ref.
Chickens tested positive for the deadly H₅N₁ virus in 17 of the 25 regencies in West Java, while human infection has been found in 12 regencies : mass culling would be conducted in 5 regencies -- Boyolali, Klaten, Karanganyar, Sukoharjo and Sragen -- where 151,000 of 161,640 chickens tested positive for the virus^ref.
Andrew Jeremijenko, head of influenza surveillance at the US Naval Medical Research Unit 2 in Jakarta, Indonesia, detected H₅N₁ in a kitten he found near a poultry outbreak in Cipedang, West Java, and tested out of curiosity on 22 Jan 2006. The virus from the kitten is closely related to recent H₅N₁ strains isolated from humans in Indonesia: it shares genetic changes found in human strains that are not present in samples from birds. Peter Roeder, a consultant for the UN Food and Agriculture Organization, says locals have an onomatopoeic name for bird flu "that sounds like 'plop', the sound of a chicken hitting the ground when it falls out of a tree. They also have a name for the cat form of avian flu — 'aaargh plop' — because cats make a screaming noise before they fall out of the tree"^{ref1, ref2}.
4 dead chickens and one ailing chicken in Batam tested positive on Sat 11 Mar 2006. The blood sample from a sick chicken in Kampung Tiban Koperasi in Sekupang had also tested positive for the H₅N₁ virus^ref. Batam is one of the islands in the Riau Islands province of Indonesia, 415 sq/km, with about 600 000 inhabitants. The island is located about 20 km south of Singapore, a mere one hour ferry ride away^ref
On Thu 23 Mar 2006 a Post-Courier front page story alleged the outbreak of the deadly bird flu virus in Timika^ref in south central Papua Province, Indonesia, which shares the same land mass with Papua New Guinea. Many people living in Kiunga and Tabubil liked to take cassowary chicks [any of several large flightless birds of the genus Casuarius of Australia, New Guinea, and adjacent areas, having a large bony projection on the top of the head and brightly colored wattles] and guria pigeons [crested or crowned pigeons, Goura victoria^ref] from the 2 towns back to their home provinces when they go on holiday breaks. But on 27 Mar the National Agriculture Quarantine and Inspection Authority (NAQIA) reported it was caused by hog cholera : the closest bird flu-infected province in Indonesia to Papua is South Sulawesi in the east and quite far from PNG^ref. Indonesia formally notified OIE on 27 Apr 2006^ref, in its first report to OIE since 6 Jan 2006) of the occurrence in March of H₅N₁ HPAI in a village near Manokwari in the north west part of the western half of the island of New Guinea (in a part of West Papua Province that Indonesia now calls Irian Jawa [Jaya] Barat Province): 15 birds were reported dead and 350 destroyed. This outbreak was previously reported in an article (in Bahasa Indonesian) in the Manokwari Post on 7 Apr 2006 (that does not appear to have been picked up by other media). Some recent media reports included mention of the outbreak in articles covering a FAO/WHO/Asia Pacific governments' meeting this week in Jakarta 'to discuss food security, poverty and preparing for disasters' (such as "Bird Flu Infects Indonesia's Papua Province as Virus Moves East'"^ref). Reuters news service has since also reported it^ref. Despite this recent media coverage, the outbreak referred to occurred 2 months ago, and appears to have been quickly and effectively eradicated. The location of Manokwari can be seen on the map^ref. New Guinea, the world's 2nd largest island after Greenland, is politically divided into 2 sections: the Indonesian provinces of Papua and West Irian Jaya in the west and the independent country of Papua New Guinea in the east^ref. This outbreak has been the closest one to Australia so far.
On 25 Apr 2006, 432 ducks (392 from a farm and the rest from its surrounding areas) smuggled from neighboring Java island were burned in Gianyar regency on Bali island^ref, after initial tests ("South Korean-made rapid testing kits") showed that 16 ducks were positive for the H₅N₁ bird flu virus^ref. A precautionary 9,500 treatment doses of Tamiflu from a separate WHO stockpile, along with protective gear, were flown into Indonesia on Fri May 26^ref.
Although outbreaks of animal disease have occurred widely throughout the archipelago, so far human cases has occurred predominantly in the central region and in northern Sumatra. The northern Sumatra cluster is geographically detached from the main body of human cases and conceivably might be associated with an atypical virus.
Dumping manure and carcasses into fish ponds, a farming method once promoted by FAO, and having them eaten by fish possibly results in ponds that
can be reservoirs for flu virus and possibility of transfer via farm fish, in bellies, on skins, or with water if live fish are transported. If fish farms play a role, just slaughtering poultry is not adequate for control, especially if a proportion of those poultry are then used as fish food^ref. In this regard, it is interesting that Webster et al. have reported H₅N₁ virus surviving for longer in fairly warm water than regular wild bird flu viruses. Scholtissek & Naylor indicated in 1988: "Global developments in aquaculture -- the so-called 'Blue Revolution' -- will mean increased colocation of people, ducks and pigs". (Fish farming and influenza pandemics;  Nature 331, 215). Depositing poultry faeces into the pond water would put any wildfowl swimming in those waters at a real risk of becoming infected...Birds faeces repeatedly trucked in for fish food would act in the same way as a constant risk to birds flying into and out of the fish pond areas". Situations resembling the one described in Indonesia may prevail in other countries as well. Aquaculture's  potential hazard in HPAI epidemiology deserves serious consideration and attention, not red herringing the role of migratory birds in spreading the virus to longer distances. It was possible that live H₅N₁ virus could be present in the intestinal tract of detritus-feeding fish, like carp, that may eat infected poultry manure or as an environmental contaminant in the intestinal tract of fish that had been raised in ponds fertilized with infected poultry manure. Live virus could also be present as an environmental contaminant in the water used to transport live fish from farm to market. Offal from commercial poultry slaughterhouses is reportedly used as a source of feed for fish farms in Thailand that raise northern snakeheads (Channa striata). The point which your correspondents seem to miss is that Indonesian subsistence farmers live in their poultry houses or rotate their families through them for security, they drink crudely filtered pond water, dress birds in the Kampong, and generally have intimate contact with poultry, live bird dealers and all they come in contact with! There is a lot of blame to go around, the inherently primitive farming system in Indonesia (Suharto's edict against corporate farming placing a 10 000-bird limit on flocks during the 1980s), lack of veterinary resources, poverty, ignorance, superstition, etc.The situation in Thailand is marginally better, especially in the commercial operations (SAHA, Sun Valley, CP), but HPAI is endemic and non-reported in the hinterland. China has done an excellent job of saturation vaccination of the intensive and semi-intensive industry segments and withholding information which is inconvenient. My conclusion is that migratory birds acquire infection and either die if susceptible or serve as transitory shedders, establishing rolling infections among diverse species. Once HPAI is introduced into an area, deficiencies in biosecurity, including primitive farming practices and live bird sales requiring movement by itinerant traders, disseminates infection. Humans with sialic acid 2-3 glycan receptors are unfortunately zapped. Please remember that the gene pool in some of the villages in Indonesia, Turkey and other areas is very shallow, or to put it another way, sibling rivalry is grounds for divorce!
Total : 53 cases, including 41 deaths (CFR = 76.5%) (28 of the 54 fatal cases in 2006)
Web resources : WHO Avian influenza in Indonesia
• Brunei : the second Bird Flu exercise (codename "Operasi Serama 2") was held at the area of Kampong Maraburong, Tutong District and the Pengiran Muda Mahkota Pengiran Muda Hj Al-Muhtadee Billah Tutong Hospital on April 3 to April 9)^ref
• Laos : since 11 Jan 2004 (first official notification 27 Jan 2004), 3300 deaths in Pong Peay village, Sangkat Phnom Penh Thmei, Khan Russei Keo, Phnom Penh (Vientiane). Initially believed them to be bird cholera, H₅N_x was confimed by RT-PCR at Pasteur Institute of Paris on Mon 26 Jan 2004. Since 27 Jan, Laos has culled > 40,000 chickens at farms around Vientiane. Most of the country's chickens, ducks and geese are raised in villages and on small farms, and only about 3 million are kept at nearly 40 small industrial farms around Vientiane : bird flu outbreaks have been confirmed at 18 of the farms. There has been no outbreak reported since February 2004. At the time of the outbreak, the river between Thailand and Lao PDR was extremely low. Migratory birds may have been attracted to remaining water reservoirs and ponds in villages and farms adjacent to the river. Almost all reports of infection came from locations close to the river. The Lao Ministry of Agriculture and Fisheries imposed a ban on the introduction of poultry from Thailand, and this decree is still in place. Check points have been established at major traffic points to monitor movements. Public awareness programs emphasize the need for improved "local" quarantine and prevention of exposure, as far as practicable, in both villages and commercial premises. Interviews with farmers revealed that, within infected farms, the disease spread more quickly where birds were kept on litter than in layer cages, suggesting that the fecal-oral route of transmission was more important than aerosol transmission. Some 20% of the national poultry flock is held in commercial enterprises servicing the larger urban human populations around the cities of Vientiane, Luang Prabang, Champasack and Savannakhet. Of these, egg producers obtain most of their replacements as "point-of-lay" 16 week-old pullets from Thailand. Similarly, day-old commercial broiler chicks are imported into farms and are available in small numbers at the larger district markets. There is no commercial production of ducks or turkeys. Village poultry in Lao PDR have close contact with each other, with pigs and with children, creating a risk of inter-species transmission. There are no large "wet" markets in Lao. Poultry are sold in the village or the local district market. The system of selling poultry in the market in Lao is unique: Consumers are offered live birds by traders in the market; birds that are not sold that day are processed and offered as fresh or cooked carcasses the following day. At the market level, this system effectively works on an "all-In, all-Out" basis. There are no large commercial poultry slaughtering establishments in Lao. Rather, processing is done by owners or traders with small basic facilities. Village poultry populations are self-replacing with few introductions from outside the village. Thus, in the event of HPAI outbreaks in the village, disease may be limited to the locality, with little risk of further spread. Active surveillance must be continued, encouraged and results recorded. On Wed May 17, 2006 FAO said that H₅N₁ had been found in a duck in Laos, but there was no sign the virus was spreading^ref. On May 2006 a duck, discovered in February 2006 by researchers on a surveillance project in the area, tested positive for H₅N₁ in a backyard farm 20 km (12 miles) south of Vientiane, the 1st since the South East Asian nation reported an outbreak among poultry in early 2004^ref. Some 20% of the national poultry flock is held in commercial enterprises servicing the larger urban human populations around the cities of Vientiane, Luang Prabang, Champasack and Savannakhet. Of these, egg producers obtain most of their replacements as "point-of-lay" 16 week old pullets from Thailand. Similarly, day-old commercial broiler chicks are imported into farms and are available in small numbers at the larger district markets. There is no commercial production of ducks or turkeys. Village poultry in Lao PDR have close contact with each other, with pigs and with children, creating a risk of inter-species transmission. There are no large "wet" markets in Lao. Poultry are sold in the village or the local district market. The system of selling poultry in the market in Lao is unique: Consumers are offered live birds by traders in the market; birds

that are not sold that day are processed and offered as fresh or cooked carcasses the following day. At the market level, this system effectively works on an "all-in, all-out" basis. There are no large commercial poultry slaughtering establishments in Lao. Rather, processing is done by owners or traders with small basic facilities. Village poultry populations are self-replacing with few introductions from outside the village. Thus, in the event of HPAI outbreaks in the village, disease may be limited to the locality, with little risk of further spread.
According to the January 2006 FAOAIDE's update No 38^ref, the following visits have been carried out recently in Laos by the agency's experts:
• Dr D Castellan (Canada) OSRO/RAS/505/USA (chief technical advisor), 20 Nov to 29 Dec 2005.
• Dr W Kalpravidh, FAO RAP (Bangkok), project coordinator, 26 Nov (?) to 20 Dec 2005.
• Dr C Bemigno, FAO RAP (Bangkok), animal health officer, USAID project, 16 to 21 Jan 2006.
• China (14 billion poultry : 12 billion chickens and 3 billion domestic waterfowl (ducks and geese); 20% of the global total)^{ref1, ref2, ref3, ref4} : the People's Republic of China comprises 31 administrative units: 22 sheng (provinces), 5 zizhiqu (autonomous regions), and 4 shih (municipalities under direct control of the central government)^ref. It also has 2 special autonomous regions (Hong Kong and Macau) and claims sovereignty over a 23rd province (Taiwan).

Ducks originating in China have been found infected with the A/H₅N₁ virus several times in recent years.
• May 2001, an avian H₅N₁ influenza A virus was isolated from Cherry Valley Pekin duck meat that had been imported to South Korea from China. The meat had been processed at a food factory in Shanghai, mainland China, brought from farms located in the Shanghai region. Phylogenetic analysis of the HA gene of A/Duck/Anyang/AVL-1/2001(H₅N₁) showed that the virus clustered with the A/Goose/Guangdong/1/96(H₅N₁) lineage and 1997 Hong Kong human isolates and possessed an HA cleavage site sequence identical to these isolates. Following intravenous or intranasal inoculation, this virus was highly pathogenic and replicated to high titers in chickens, while no clinical signs of disease were observed in inoculated ducks. However, the infectious virus could be detected in lung tissue, cloacal, or oropharyngeal swabs of the inoculated ducks. Virus inoculations in mice caused weight loss and resulted in 22-33% mortality. The said results led the writers to the conclusion that HPAI H₅N₁ virus strains are still circulating in China and may present a risk for transmission of the virus to humans^{ref1, ref2}.
• May 2003 : an influenza A (H₅N₁) virus was isolated from duck meat processed for human consumption, imported to Japan from Shandong Province, China. This virus was antigenically different from other H₅ viruses, including the Hong Kong H₅N₁viruses isolated from humans in 1997 and 2003. Sequence analysis revealed that 6 genes (PB1, PA, HA, NA, M, and NS) of this virus showed > 97% nucleotide identity with their counterparts from recent H₅N₁ viruses, but that the remaining 2 genes (PB2 and NP) were derived from other unknown viruses. This duck meat isolate was highly pathogenic to chickens upon intravenous or intranasal inoculation, replicated well in the lungs of mice and spread to the brain, but was not as pathogenic in mice as H₅N₁ human isolates (with a LD₅₀ of mice (MLD₅₀) = 5 x 10⁶ = 50% egg infectious doses [EID₅₀]). However, viruses isolated from the brain of mice previously infected with the virus were substantially more pathogenic (MLD₅₀ = approximately 10² EID₅₀) and possessed some amino acid substitutions relative to the original virus. These results show that poultry products contaminated with influenza viruses of high pathogenic potential to mammals are a threat to public health even in countries where the virus is not enzootic and represent a possible source of influenza outbreaks in poultry. Significant features of this report are:
• the apparent survival of an avian influenza virus in processed duck meat destined for export
• the antigenic distinctiveness of this virus from other H₅N₁ viruses known to be in circulation between 1997 and 2003, notwithstanding the> 97% nucleotide identity of the HA and NA genome subunits
• the characterization of this virus as a reassortant with 2 genome subunits from one or more unknown influenza virus.
Biological characterization of the virus in mice suggested that it was less pathogenic than human isolates of H₅N₁ viruses but that it had potential to be come more virulent, although extrapolation from mouse to man seems a dubious procedure at this stage of knowledge. Perhaps the most intriguing feature of this report is the unresolved identity of the influenza virus (or viruses) contributing the PB2 and NP genome subunits, which one must assume was/were circulating in some host somewhere in China at that time or before^ref.
• December 2003, A/H₅N₁ strains were isolated from tracheal swabs taken before the destruction of 6 smuggled ducks in Taiwan^ref
A 24-year-old man, who served in the army, had pneumonia and respiratory distress on November 25, 2003, the year China experienced the severe acute respiratory syndrome (SARS) outbreak. He was rushed to the No 309 Hospital of the People's Liberation Army on Nov 30, but died of pneumonia without clear cause on December 3, 2003^ref. Because the clinical manifestations were consistent with those of the SARS and occurred when sporadic cases of SARS were described in southern China^ref, serum and lung tissue from the patient, as well as fluid aspirated from his chest, were examined for SARS coronavirus with the use of indirect fluorescence antibody tests and the reverse-transcriptase polymerase chain reaction (RT-PCR). All tests were negative for SARS. A virus was isolated from the lung tissue in Vero-cell cultures and was characteristic of influenza A virus on electron microscopy. A serum sample collected on day 8 of the patient's illness was positive for IgM antibody against the isolated virus. Fragments of both the influenza A virus matrix gene (M) and the H₅-subtype hemagglutinin gene (HA) were amplified from the infected Vero cells with the use of RT-PCR assay^{ref1, ref2}. The nucleotide sequences of the fragments were identical to those amplified from the stored specimens of the patient's serum, chest fluid, and lung tissue. The genomic sequence of the virus (A/Beijing/01/2003) was determined, and its eight segments were genetically related most closely to corresponding sequences of influenza A (H₅N₁) viruses that had been isolated from chickens in various regions of China in 2004. The segments of the polymerase basic protein 1 gene (PB) and the nonstructural gene (NS) were most closely related to those from Guangdong Province (in southeastern China), with 99% identity. The segments of the polymerase basic protein 2 gene (PB2) and HA gene were closest to those from Jilin Province (in northeastern China), with 99% and 97% identity, respectively. The segments of the neuraminidase gene (NA), nucleoprotein gene (NP), and M gene were closest to those from Hubei Province (in mideastern China), with 98%, 98%, and 99% identity, respectively, and the polymerase acidic protein gene (PA) segment was closest to that from Japan, with 99% identity. These findings suggest that influenza A/Beijing/01/2003 may be a mixed virus. Phylogenetic analyses of the HA and NA genes of the representative influenza A (H₅N₁) strains have revealed that the viruses isolated from patients in Thailand and Vietnam in 2004 and 2005 belong to the same clade, and those obtained from patients in Hong Kong in 1997 and 1998 are from another clade. A sample of virus obtained from a patient in Hong Kong in 2003 seems to represent a transitional genotype, of which the HA gene sequence was close to the cluster from southeastern Asia, whereas the NA gene sequence was close to that of the cluster from Hong Kong in 1997 and 1998. Phylogenetic analyses of the HA or NA gene indicated that the influenza A/Beijing/01/2003 strain was genetically distant from viruses previously isolated from humans, although it appears to have originated from a lineage similar to the influenza A/goose/Guangdong/1/96 (Gs/GD) lineage^ref. These findings have important implications for selecting viruses for the development of vaccines to prevent infection in humans. The genetic distance between the isolate reported and the strain currently proposed for vaccine development (A/Vietnam/1203/2004)^ref implies that viruses from different regions may need to be considered in the development of an effective vaccine against influenza A virus^ref. This case was the same time that the virus had started taking human lives in some other countries, Vietnam, Thailand. At least one scientist e-mailed the New England Journal of Medicine Wednesday morning, asking that the report be withdrawn. With the article already in print, journal editors were waiting to see whether the authors would now retract the paper. "We can't speculate" what the problem was, said journal spokeswoman Karen Pedersen^{ref1, ref2}.
On 19 Jan 2004 a single scarce resident and winter visitor peregrine falcon (Falco peregrinus : a predator perhaps infected from eating a duck) was found dead due to H₅N₁ near a residential development at Gold Coast, New Territories, < 11 km (7 miles), from the border between Hong Kong, a special autonomous region of China, and Shenzhen, an adjacent Chinese city, near 2 chicken farms in Hong Kong, that had the virus. > 10 000 bramblings (small birds that are members of the finch family with an orange breast and shoulder patch, a white rump, and a black tail -- fly south from China's north east every winter) dropped like "bird rain" from the sky over Communist Party chief Hu Jintao's birthplace Taizhou, in the eastern coastal province of Jiangsu, on Tuesday, considered a bad omen at the beginning of the new lunar year : a toxic cloud that the birds flew through may have caused such a death. Teflon is know to produce sudden deaths in avians. Chlorine gas could also cause such a phenomenon, but it would likely have affected people as well. Storms are known to cause some problems with some birds, but there is no mention of it here. The first HPAI case in China was confirmed in Long'an County of Guangxi Province on 27 Jan 2004. Afterwards, 49 laboratory confimed bird flu outbreaks^{ref1, ref2} in poultry, ducks, geese, and doves, in 16 mainland regions of the country's 31 provinces, autonomous regions, and municipalities have so far been found infected (date of first report in brackets):
• 1. Guangxi Zhuang Autonomous Region (27 Jan 2004; first official notification 28 Jan 2004) :
• a duck farm in Long'an County. The local government sealed the affected area, destroyed all poultry within a radius of 3 kilometers, and quarantined all poultry within a radius of 5 km in line with laws and regulations
• Xingning district, Nanning city (suspected)
• 2. Hubei Province, central China (26 Jan 2004)
• Wuxue County :
• Ezhou city
• Xiangfan City
• Macheng city (10 Feb 2004)
• Yichang city
• Honghu  City
• Gongan county
• Songzi city
• Yangxin county
• Huangmei county
• 3. Hunan Province, central China (26 Jan 2004) :
• a duck outbreak in Wugang County confirmed on Jan 31
• Pingjiang County
• Shaodong county
• Heshan district, Yiyang city
• Suxian district, Chenzhou city
• 4. Anhui Province, east China (30 Jan 2004) : in Fuyang and Jieshou cities. 1 case in doves (3 Feb 2004)
• Yushan district, Maanshan city
• Guangde county, Yingzhou district, Fuyang and Jieshou city
• Gansu Province Gaolan county
• 5. Guangdong Province, south China (30 Jan 2004)
• Chao'an county
• Haifeng county : Luoding city (suspected)
• Jiedong county
• Doumen district, Zhuhai city (suspected : > 1000 chickens died at a poultry farm in Doman Sangli village on 8 Feb 2004)
• Jiangcheng district, Yangjiang city, Shenzhen city, Nanxiong city
• Maogang district, Maomin city
• 6. Shanghai (30 Jan 2004) : Nanhui district, an eastern suburb
• 7. Zhejiang Province (1 Feb 2004) : Yongkang city
• 8. Yunnan Province, southwest China (1 Feb 2004) :
• Guandu District : Kunming city, Yunnan's capital city
• Chenggong County
• Xishan district : Kunming city and Anning city (10 Feb 2004)
• Shilin county
• Songming county (suspected)
• Tianjin Jinnan district
• Zhejaing Province Yongkang city
• Shanghai Nanhui district
• 9. Henan Province (1 Feb 2004) : Pingyu county
• 10. Xinjiang Autonomous Region 12th Agriculture Division under the Xinjiang Production and Construction Corps (1 Feb 2004)
• 11. Gansu Province, northwest China (1 Feb 2004) : farms in
• Gaolan County (?)
• 12. Shaanxi Province, northwest China (3 Feb 2004) :
• Changan district : Xi'an City
• Huayin city (10 Feb 2004)
• 13. Jiangxi Province (6 Feb 204)
• Qingyunpu district : Nanchang city
• Dongxiang county : Guixi city
• 14. Tianjin's Jinnan district (10 Feb 2004)
• 15. Xizang (Tibet) Autonomous Region : Yaowangshan live poultry wholesale market, capital Lhasa (about 3,600 m (11 800 ft) above sea level). Himalayan region's (one of China's poorest regions, which is home to about 2.7 million people and is famed for its Buddhist tradition). Reports suggested that the introduction of H₅N₁ to Lhasa in January 2004 followed the movement of poultry from Lanzhou, Gansu province, China; a distance of approximately 1500 km (FAO 2004). The death of poultry from an identical viral strain in locations many kilometres apart says nothing about how the virus was transferred between the 2 places. Major railway lines link southern China to Kazakhstan, Russia and Eastern Europe, and many believe these could be a route for transmission of the virus from Asia to Eurasia^ref.
• 16. Jilin Province, northeast China : Zhenlai county, Baicheng City
Lifting of isolation measures began on 22 Feb 2004 after 21 days of  isolation. 4 of the infected provinces have common borders with neighboring countries: Yunnan (Burma, Laos and Viet Nam); Guangxi (Viet Nam); Gansu (Mongolia); Xinjiang (Pakistan, Afganistan, Tajikistan, Kyrgyzstan, Kazachstan, Russian Federation and Mongolia). The cumulated number of diseased birds is 144 800, of which 127 900 have died; 9 016 300 have been culled and 10 211 800 poultry have been compulsorily vaccinated. As of 19 Mar 2004 there have been no new epidemic reports in China for 32 consecutive days. And cordons on epidemic areas have been lifted. Meanwhile, some black swans died unusually in a wild zoo in Shenzhen, Guangdong's boomtown neighboring Hong Kong. H₅ serotype viruses are generally less fatal to ducks, so it is uncommon for so many ducks to die and this means this particular strain of AI A(H₅N₁) virus has become more virulent. Asia's growing prosperity has been accompanied by a boom in intensive poultry production : after 1997, when all the chickens in Hong Kong were destroyed after H₅N₁ bird flu killed 6 people, Chinese producers decided to take no chances, and started vaccinating birds with inactivated H₅N₁ virus. This may have been a mistake : if the vaccine is not a good match for the virus -- as is the case with the H₅N₁ strain now sweeping Asia -- it can still replicate, but most animals do not show signs of disease. In this way, the intensive vaccination schemes in south China may have allowed the virus to spread widely without being spotted. The outbreak of bird flu comes just weeks ahead of the lunar new year celebrations, traditionally marked by feasting and festivities in China and by Chinese people across Asia, pushing poultry sales higher. Controlling outbreaks in China, which raised 8 billion chickens in 2003 and before the AI outbreak was expected to produce some 10.1 million tonnes of poultry in 2004, is worrisome to health experts because nearly 60-80% of of China's 13.2 billion chickens, ducks and other fowl are raised on household farms, where peasants live in close proximity with their animals. The lowest price of chicken wings per kilogram has dropped to 20 yuan (USD 2.41). Now it is 23.8 yuan (USD 2.87), but still lower than the usual 27 yuan (USD 3.25). There has been no outbreak since July 2004. The Ministry of Public Health has recently discussed an emergency program to guard against HPAI. Large cities have stepped up surveillance. Yunnan Province, which shares a 1200 km border with Viet Nam, has taken emergency measures to prevent HPAI from spreading from Viet Nam into China. Poultry farms, regions on the China-Viet Nam border, and places that experienced HPAI early in 2004 have been urged to vaccinate poultry. The provincial government is encouraging local agriculture, health, import and export quarantine, public security, quality inspection and customs officers to work together to monitor the spread of HPAI and to become better informed on the distribution of poultry and egg products. The local animal husbandry department has set up a 30-km-wide "immune protection zone" in the area bordering Viet Nam and has established disinfection stations at the frontier crossings and border ports to check and disinfect all vehicles and personnel crossing. Any outbreak of bird flu must be reported to authorities within 24 hours.
21 H₅N₁ flu virus samples taken from apparently healthy ducks, which act as a natural reservoir for the disease, in southern China between 1999 and 2002 inoculated into chickens, mice and ducks : as expected, ducks were immune to the virus's effects and the chickens fell sick. However, the mice also became ill, losing weight and the use of their limbs. Crucially, the severity of their illness was linked with the year from which the virus sample was taken : viruses isolated in 2001 and 2002 made the animals more ill than those isolated earlier on^ref. These observations conflict with the results of previous phylogenetic analysis, which indicated that AI viruses from wild fowl have not evolved much over the past 60 years in contrast to mammalian viruses, and as a consequence it has been concluded that influenza viruses in wild birds appear to be in "evolutionary stasis". A series of genetic reassortment events traceable to the precursor of the H₅N₁ viruses that caused the initial human outbreak in Hong Kong in 1997, and, subsequent avian outbreaks in 2001 and 2002 gave rise to a dominant H₅N₁ genotype (Z) in chickens and ducks that was responsible for the regional outbreak in 2003-2004. Domestic ducks in southern China had a central role in the generation and maintenance of this virus, and, also, wild birds may have contributed to the increasingly wide spread of the virus in Asia. H₅N₁ viruses with pandemic potential have become endemic in the region and are not easily eradicable. These developments pose a threat to public and veterinary health in the region, and, potentially, the world, and suggest that long-term control measures are required^ref.
Sus scrofa tested positive for H₅N₁ viruses in 2003 and 2004.
On 14 Apr 2005, 2 Taiwanese men were arrested for allegedly smuggling nearly 4 tons of raw duck tongues from about a million ducks from China, with a retail value of about NT 10 million (USD 317 000) : they were destroyed immediately. Cooked duck tongues are a delicacy among many locals and Hong Kong tourists^ref.
The national bird flu reference laboratory confirmed, on Tue 6 Jul 2004, that H₅N₁ caused 1520 deaths since 24 Jun at a chicken farm of the Juchao District, Chaohu City, east Anhui Province : 6640 animals were culled. Since the farm is close to Chaohu lake; it is very possible that the disease was transmitted by migratory birds and wild waterfowl. It was China's 1st report of the avian illness since it declared it had "stamped out" the disease nearly 4 months ago.
Since Apr 15 2005, >  6,000 migratory birds of 5 species (90% were bar-headed goose Anser indicus (which breeds on Bird Island in Qinghai Hu (Koko Nur)), but also great black-headed gull (Larus ichthyaetus), brown-headed gull (Larus brunnicephalus), ruddy shelduck (Tadorna ferruginea) and great cormorant (Phalacrocorax carbo)) at Lake Qinghai Nature Reserve, the nation's largest saltwater lake, in Niannaisuoma village, Quanji town, Gangcha city of the western province of Qinghai, neighboring Tibet and Xinjiang, between 4 and 8 May 2005 was caused by the deadly H₅N₁ virus, the 1st report of H₅N₁ detected in China since 2004. China has rushed >3 million doses of bird flu vaccine there. Bar-headed geese breed in Central Asia (mainly China and Mongolia), and most of the population winters in India, with smaller numbers in Pakistan, Nepal, Bangladesh, northern Myanmar and southwest China. Waterfowl populations can be broadly separated into "flyways." These indicate the migration route used during migration and the breeding and wintering areas that the route connects. Bar-headed geese which have been banded/ringed at Niao Dao subsequently have been recorded in India (as far west as Karnataka) in the Central Asian Flyway; Cao Hai, Guizhou Province, China in the East Asian Flyway; and Bangladesh, which is in an area where the 2 flyways overlap. There could be potential for future spread of virus between waterfowl populations through mixing on the wintering grounds, thereby facilitating a natural north/west spread of virus through the Central Asian Flyway. Most of these species do not migrate to Southeast China or to Southeast Asia. Some, such as the bar-headed geese, fly southwest for the winter to India and Bangladesh. There have been no reports of H₅N₁ outbreaks in India or Bangladesh occurring this past winter, reasonably suggesting that migratory birds neither carried H₅N₁ with them from China last fall, nor returned with it this spring. If there was a high mortality in Quinghai, it would suggest that H₅N₁ is also highly pathogenic to the wild species affected, rather than making them likely sub-clinical carriers -- as domestic ducks are. The percentage mortality of the various wild species has not been reported, nor has the percentage of dead birds that tested positive for H₅N₁. More likely than migratory birds bringing the virus from India or Bangladesh, uninfected wild birds arriving on summer breeding grounds in China could have easily been infected by local domestic ducks (or domestic chickens or geese) close to the end of the migration route. The migratory birds are still on the island, but they will begin flying to other parts of China and neighboring countries in about a month : many asymptomatic birds can fly from here to 1000 km (621 miles) further up. Chinese authorities have cordoned off a 50-km (31-mile) radius around Lake Qinghai and nature reserve. However, the WHO says only 12 birds and 2 people (out of nearly 600 people who had contact with the wild birds) have been tested for the strain and found negative so far because the population is so dispersed: China has not carried out a cull of the birds, a common practice with infected domesticated flocks, because they are rare and protected species. Samples of 12 dead birds have been sent to the national laboratory in Harbin, Northeast China's Heilongjiang Province, for testing. Indeed, more testing is required to accurately assess if the avian influenza virus is the only or main causative agent of the mass mortality observed among several water-bird species at Lake Qinghai. The pathogenicity of the virus should preferably be tested in wild birds of the same species, as well as in poultry. In addition, other etiological factors, including clostridial toxins, should be ruled out. By 4 May 2005, bird mortality was > 100 a day; by 20 May 2005, the outbreak had spread to other islets, with some 1500 birds dead. On 29 Jun birds are still dying in Qinghai Province at the rate of 20 a day.  28 H₅N₁ viruses were isolated from 92 cloacal, tracheal and faecal swabs from all 3 species, and a further 5 viruses from tissue samples from bar-headed geese. Sequence comparison revealed that the H₅N₁ viruses were almost identical across all gene segments. The haemagglutinin gene retains the motif of basic amino acids (QGERRRKKR) in the connecting peptide that characterizes HPAI. All Qinghai isolates had a E627K mutation in the PB2 gene, which has been associated with increased virulence in mice. Phylogenetic analysis of these isolates and 8 other H₅N₁ viruses, isolated from poultry markets in Fujian, Guangdong, Hunan and Yunnan provinces during 2005, indicated that the haemagglutinin, neuraminidase and nucleoprotein genes of the Qinghai viruses were closely related to the H₅N₁virus A/Chicken/Shantou/4231/2003 (genotype V). However, the other 5 internal genes, represented by the matrix-protein gene, were closely related to H₅N₁ viruses isolated from domestic poultry in southern China during 2005, represented by the virus A/Chicken/ Shantou/810/2005 (genotype Z). These viruses are therefore characterized as H₅N₁ genotype Z, but are clearly distinguishable from those that have caused human infection in Thailand and Vietnam. This indicates that the virus causing the outbreak at Qinghai Lake was a single introduction, most probably from poultry in southern China. Qinghai Lake is an important aggregation and breeding site for bar-headed geese that are distributed over central Asia. From September, they migrate southwards to Myanmar and over the Himalayas to India, returning to Qinghai around April. The findings indicate that H₅N₁ viruses are now being transmitted between migratory birds at the lake. Although the outbreak could burn itself out, the large migratory bird population at Qinghai Lake makes this unlikely. The viruses might also move to other migratory species that could act as carriers, remaining highly pathogenic for domestic chickens and possibly humans. Like its precursor, A/Goose/Guangdong/1/96, the current H₅N₁ virus could become established in bar-headed geese. There is a danger that it might be carried along the birds' winter migration routes to densely populated areas in the South Asian subcontinent, a region that seems free of this virus, and spread along migratory flyways linked to Europe. This would vastly expand the geographical distribution of H₅N₁. Increased surveillance of poultry is called for, because previous experience has shown that control measures become almost impossible once the virus is entrenched in poultry populations^ref. The Chinese Ministry of Health, plus 6 other ministries including the Ministry of Science and Technology Authority, Education Authority, and Health Authority signed on Jul 6 2005 new rules about AI. Rule number 4 of the new act states that no other entity except for the Veterinary Bureau within the Ministry of Agriculture can disseminate information on animal diseases. The final rule warns that "legal action will be taken against a person who defies these laws"^ref. None of the article's writers have been to Qinghai Lake to collect samples, and the migratory birds in Qinghai Lake, which fly to China from the west, will not pass the southern and eastern parts of China, so the article's conclusion lacks credibility, said Jia Youling, a Ministry of Agriculture spokesman and director general of the Veterinary Bureau. No bird flu has broken out in southern China since the beginning of 2005, and the writers' laboratory lacks the basic conditions for biological safety. The writers did not apply government approval for carrying out such bird flu virus research^{ref1, ref2}. Yuen Kwok-yung research into the AI strain at the center's Shantou laboratory had been suspended after its director Guan Yi, a University of Hong Kong virologist, was told his investigation was in violation of biosafety laws recently implemented by the Chinese Ministry of Agriculture^{ref1, ref2}. Guan had collected H₅N₁ strains from apparently healthy chickens and sequenced them—actions that were technically outside the law because he did not have permission to gather strains that had the potential to cause a pandemic in animals : they were collecting samples from healthy looking chickens and poultry, and then theoretically they're not affected by AI... so they are not collecting outbreak strains or viruses, but some of the viruses, as it turns out, contain genetic characteristics of pathogenic viruses, so they should not be collecting these for that particular lab in Shantou. Regarding the presence of H₅N₁ in southern China^ref. There are some questions awaiting clarifications in this case, such as the exceptionally high mortality in wild waterbirds of different species. What was their respective susceptibility? Which other 5 viruses have been isolated? Could other factors, additional to H₅N₁, have played their role?  A reply, excluding  other potentially plausible etiologies, such as botulism, comes from a second work : "On 4 May 2005, a few birds were found dead on "Bird Island" and by the end of June more than a thousand birds were affected. This lake is one of the most important breeding locations for migratory birds that overwinter in Southeast Asia, Tibet and India. Several species were infected, including the bar-headed goose (Anser indicus), great black-headed gull (Larus ichthyaetus) and brownheaded gull (Larus brunnicephalus). 2 key symptoms were noticed: abnormal neurological signs (tremor and opisthotonus) and diarrhea. Among the gross lesions, pancreatic necrosis was obvious and was confirmed by tissue section where extensive areas of lytic necrosis were seen, consistent with pathology observed in domestic geese and ducks infected with H₅N₁AIV. Brain sections revealed glial cell infiltration, perivascular cuffing, and congestion in the blood vessels. Serological tests from one bar-headed goose and one brown-headed gull confirmed the presence of high-titer antibody against H₅N₁ AIV. Several H₅N₁ viruses were isolated from the viscera, brain and the swabs of the oropharynx and cloaca of sick and dead birds. 4 of the isolates from different bird species were completely sequenced and appeared to be closely related. None of the GenBank sequence data for known H₅N₁ AIV genomes completely matched our sequences, implying the viruses are reassortants. 5 of the 8 genomic segments (M, PA, PB1, PB2 and NS) were closely related to a Hong Kong 2004 isolate (A/peregrine falcon/HK/D0028/04). We observed several characteristics in our 4 isolates: first, the sequence, PQGERRRKKR/G, denoting multiple basic amino acids at the cleavage site of the haemagglutinin (HA); 2nd, a virulence island in the PB2 gene, E627K, first seen in Hong Kong in 1997 (5); and 3rd, a deletion of 20 amino acids in NA (amino acid position 49-69), also associated with high virulence. To test virulence, mice and chickens were infected with the BhGoose/QH/1/05 isolate. All 8 infected chickens died within 20 hours and 7 of 8 infected mice died within 72 hours, and the last died 96 hours post-infection. Earlier isolates taken from ducks in China were less virulent in mice and chickens. Hence viruses might be emerging from reassortants originating in birds overwintering in Southeast Asia. The occurrence of HPAI H₅N₁ virus infection in migrant waterfowl indicates that this virus has the potential to be a global threat: Lake Qinghaihu is a breeding center for migrant birds that congregate from Southeast Asia, Siberia, Australia and New Zealand"^ref. The paper does not mention the number of birds sampled. Reportedly the Chinese have vaccinated 2 million chickens in the region following the Qinghai outbreak.
Chinese agriculture officials are quoted as saying that migratory birds may have brought the virus from South East and Central Asia, so other parts of China should not be affected. There are 3 major migrating routes for birds in China. The recent outbreak appeared in the western route, from south and central Asian countries to the northern part of the Indian Peninsula then over Tibet and the Himalayas to Qinghai province. Because the bar-headed geese that were killed most in this outbreak were only found on this route, so other parts of China won't be affected. However it is unclear from the media reports whether the identity of the Qinghai virus has been determined. It is important not to jump to conclusions; c.f. the late 2004 report of H₅N₁ in a mallard (Anas platyrhynchos) in Siberia. Other factors, infectious or otherwise, might be involved and should be ruled out prior to final incrimination of the demonstrated virus strain as the sole causative agent. Apparently, as many as 100,000 birds congregate on this lake, and so 500 dead birds may not be unusual, and it is possible that avian influenza was isolated from birds that died of something else. Cause-of-death determinations may have been done, but those data are not publicly available presently. If they were not done, it may be too late to determine cause-of-death in this case, but such determinations are a critical part of any disease outbreak. We don't know how many of these 519 birds actually had avian influenza. In some die-offs, detailed investigation is done on a few animals, and then the results of those investigations are extrapolated to the rest of the dead animals. H₅N₁ avian influenza is known to be circulating in domestic poultry in Southeast Asia, but very few wild birds have been found with the virus there. It is possible that one of these 5 bird species (or one of the many other species that congregate at Qinghai) brought the virus to the preserve from Southeast Asia. Alternatively, it is also possible that there is an unreported outbreak of H₅N₁ in domestic poultry in central China from which the wild birds picked up the virus.
In a Chinese language news site where people can post articles, there are unsubstantiated reports of 121 human deaths in 18 villages in Qinghai Province due to an unknown cause since the end of April 2005. Some bloggers have speculated that these are human cases of influenza, but at this point there, is no evidence for or against this theory. After 1 May 2005, some tourists who visited the areas were severely affected, and 6 of them died: 2 (a man and a woman) from Chengdu, and one man from Chongqing, Sichuang province. It is unknown from where the remaining casualties come. During the month of April 2005, a large-scale dissemination of the infection took place involving both humans and domesticated animals. The affected area is vast but sparsely populated. Thus, the problem of large-scale of infection involving both humans and domesticated animals is relatively unnoticeable. The feral birds migrate freely and  so expand the area of transmission. The Chinese authorities have admitted the outbreaks and started to seal off the affected area. This unofficial information needs substantiation : Chinese health authorities have denied Internet reports that there have been human infections and deaths caused by the H₅N₁ influenza virus in their country, the head of the World Health Organization's influenza branch said on Wed 25 May 2005.
Though AI virus has been isolated from geese in various countries, clinically manifested disease is not common in this species. In China, outbreaks of disease due to HPAI viruses of the H₅ subtype were not reported in geese until 1996. During the summer and early fall of 1996, an outbreak of disease with 40% morbidity occurred on a goose farm in Guangdong Province. At least 2 influenza A (H₅N₁) viruses from sick birds were isolated. The pathogenicity of one of these isolates, A/Goose/Guangdong/1/96, was evaluated in experimentally-inoculated geese and chickens and found to cause disease and death in these birds^ref. The total number of H₅N₁ outbreaks, reported by China throughout the regional panzootic, which started at the end of 2003, is 50 -- compared to significantly higher figures in neighboring Thailand (1092) and Viet Nam (1837). China's last report on its HPAI H₅N₁ situation was sent to the OIE on 6 Jul 2004. For fairness sake, it should be mentioned that in China, mass vaccinations in chickens and in domestic ducks and geese are widely applied, preventing infections or suppressing clinical manifestation of the disease.
China plans to launch an early warning system to detect and prevent the spread of bird flu in cases similar to the recent outbreak of the virus in northwest China, authorities said on 31 May 2005. The network will be based on a wide array of information technologies. The system will feature a nationwide virus database, epidemic analysis and information sharing among foreign experts and regular information releases to the public. The development of a state-of-the-art animal-disease warning system in China should be warmly welcomed by all concerned about the current rate of transparency regarding avian influenza. This is underlined by the fact that China's agriculture maintains 62% of the world's duck population (661 million out of 1065 million) and 49% of the world's pig population (457 million out of 940 million) (FAO statistics, 2002). In the meantime, essential data are expected to become available by means of the existing animal disease surveillance systems, supported by the reputable Chinese diagnostic laboratories. A current example: data on suspected avian influenza in migrating birds were initially mentioned in the media on 10 May 2005. China officially notified the incident to the OIE on 23 May 2005, incriminating avian influenza virus type H₅N₁ as the causal agent killing 519 wild birds of 5 species (a number which seems to have increased to 1000 according to subsequent newswires). An AI virus which will kill such numbers of wild birds belonging to different species and within a short time frame seemed rather exceptional.
2 outbreaks occurred in the north western Xinjiang autonomous region (which borders the province of Qinghai, where an extensive outbreak in wild geese and other wild birds was eventually reported by the Chinese authorities on 21 May 2005, and 25 km from the border with East Kazakhstan)
• an index farm in Tacheng city, Chuguchak (Tacheng) district in SUAR province,  had 2177 geese, 1042 were positive for H₅N₁, and, as of 8 Jun 2005, 460 had died. 13,457 birds were culled in order to contain the new outbreak. Xinjiang authorities have adopted various control measures, including modified stamping out and vaccination.
• a second outbreak in this region was reported by the Ministry of Agriculture (MOA) on June 21 2005 : 128 geese and ducks were infected and 63 died. The authorities have culled 1490 birds, including the infected geese and ducks and those raised in nearby farms : the outbreak is now under control
Rumors, denied by the government, affirmed that the Chinese Agriculture Ministry approved the production and sale of the drug amantadine for use in chickens, although such use is barred in the USA and many other countries. China's use of amantadine both to treat chickens sickened by bird flu and to prevent healthy ones from catching it was widespread since 1990s (it was introduced into China in the 1970s for human use), although China did not report an avian influenza outbreaks of its poultry until February 2004, according to pharmaceutical company executives and veterinarians. Local government veterinary stations instructed Chinese farmers on how to use the drug and at times supplied it. Amantadine is widely used in the entire country : many pharmaceutical factories around China produce amantadine, and farmers can buy it easily in veterinary medicine stores. Amantadine sells for about US$10 a pound, a fraction of the drug's cost in Europe and the USA, where its price would be prohibitive for all but human consumption. In 1987, researchers at a U.S. Department of Agriculture laboratory demonstrated that bird flu viruses developed drug resistance within a matter of days when infected chickens received amantadine. Both amantadines, the cheapest drugs against flu, are now ineffective against the H₅N₁ strain. The Chinese Ministry of Agriculture (MOA) plans to dispatch inspection teams nationwide to stop. It is not clear where and how amantadine is applied in poultry. This seems an uneconomical, and most probably inefficient drug for mass protection/treatment of commercial poultry against HPAI. Is it possible that the application is undertaken to protect electively expensive birds, such as fighting cocks, or that some financial interests of suppliers/professional advisers are at the background exploiting the misery and trust of naive farmers? On top of that, the efficacy of such treatment is doubtful. The WHO Collaborating Center for Reference and Research on Influenza and the WHO H₅ Reference Laboratory in the National Institute of Infectious Diseases, Japan found that all 9 tested viruses isolated from specimens collected from confirmed and suspected H₅N₁ human cases in southern Viet Nam between 24 Dec 2004 and 29 Jan 2005 showed genetic resistance to amantadine. Previously, several avian influenza virus strains of hemagglutinin subtype 5 were found to exhibit resistance against amantidine^ref. Amantadine was developed by Du Pont > 30 years ago and has not proven to have much application in control of human influenza. (But Webster and colleagues have described a possible strategy for employing amantadine in conjunction with vaccine). The target of the drug is known now to be the M-2 protein (which forms a transmembrane ion channel transporting protons). Amantadine blocks ion transport in the case of all influenza A viruses, but not influenza B viruses because influenza B virus does not express a M-2 protein. Mutation to amantadine-resistance occurs at appreciable frequency and this has limited the use of amantadine in human medicine. Another factor limiting its use in humans is that it must be administered 24 hours before exposure to infection and it must be maintained at high concentration for at least 10 days. Side effects are common, particularly those affecting the CNS. Amantadine survives as a therapeutic drug, not because of its anti-influenza A virus activity, but because it has some beneficial use in treatment of Parkinson's disease. A methylated derivative -- rimantadine -- was developed in Russia which does not cross the blood-brain barrier and consequently has fewer neurological side-affects.
> 300 egrets died in a Guangzhou forest park in Baiyun District on Jul 2005 (20 to 30 every day) : some villagers blamed the heat, but others feared it was linked to the bird-flu virus and urged the government to investigate. There are people who have started eating egrets, with some being cooked on barbecues : people had also caught the sick birds to sell at markets. Bird die-off might be caused by a multitude of causes; laboratory investigation is essential to confirm -- or exclude -- the involvement of avian influenza. However, no such investigation is necessary to convince folk that consuming dead egrets is not recommended. Electronic tracking devices can be implanted into a bird's back, but they cost thousands of dollars a bird, including the price of the receiving station necessary to monitor the birds' movements. The forestry bureau has asked China's Finance Ministry for more funding, and that request is pending
But even as governments spend millions of dollars on preventive measures, tracking the birds remains a problem. Back in 1983, when Chinese park rangers tagged migratory birds that visited Qinghai Lake for a research project, they used nets : the tactic worked, but too many birds choked to death
as a result. > 2 decades later, without nets, the task has proved far more difficult. Brazilian ornithologists have had no trouble catching and banding hundreds of adult shore birds in nylon mist nets on their migration routes. They do not choke to death as long as the nets are checked frequently.
Since 1 Aug 2005, 133 chickens out of 2608 infected with H₅N₁ HPAI (diagnosed by HI on Aug 4 and by RT-PCR and IVPI on Aug 10) died in a farm belonging to the Regional Institute of Animal Husbandry Science close to the capital Lhasa, capital of southwest China's Tibet Autonomous Region (the 3rd region hit in China, probably infected from western provinces of Xinjiang and Qinghai), which prompted authorities to cull an additional 2475 birds in the surrounding area. Vaccination has been applied, using an inactivated monovalent H₅N₂ vaccine, to all areas across Tibet except Ngari Prefecture^ref.
New outbreaks occurred since Oct 2005 :
• Inner Mongolia : since 14 to 19 Oct 2005 2,600 birds died of the H₅N₁ strain of bird flu in a breeding facility in Tengjiaying village (500 km west of Beijing in the Eastern part of Inner Mongolia (Lat: 40 49 00 N Long: 111 37 00 E)), near Huhehot municipality, the capital of Inner Mongolia^ref : the epidemic was placed under control after  91,100 birds (3400 in the oubtreak area and 87 700 birds outside the outbreak) were destroyed and 166,177 birds in Inner Mongolia have been vaccinated with monovalent inactivated vaccine against subtype H₅N₂^ref. On 15 Nov an outbreak in Wulan village, Molidawa Dawo'er autonomous county klled 176 birds and 3202 were culled. On Nov 25 a new outbreak was reported in the northern Inner Mongolia region, bringing the total number of outbreaks for the country in recent weeks to at least 23 : the latest outbreak killed 246 birds (3380 slaughtered) at a farm in Dashuiquancum village, Zalantun city, on Nov. 20, prompting officials to kill 16,567 birds in the area^ref

Anhui province : since 20 Oct 2005 an outbreak of HPAI H₅, in the village Liangying, involved chicken and goose and was confirmed by the laboratory on 24 Oct 2005 based upon HI, RT-PCR and IPVI tests : almost 45 000 birds were destroyed. In response to the outbreak, 140 000 avians have been vaccinated with an inactivated mono H₅N₂vaccine. Anhui province was reportedly infected with HPAI in 2004; an export ban on poultry products was imposed by China's quarantine authority on 7 Jul 2005, lifted on 31 Aug 2004 following the declared eradication of the outbreak. An 20 Oct 2005 outbreak in the city of Tiancheng killed about 550 birds. Qiao Songju, a resident of Gaoyou county in Jiangsu province, attained a brief heroic reputation for informing authorities of a massive bird-flu outbreak in Anhui province in October 2005. Tipped by Qiao, the Ministry of Agriculture confirmed the outbreak of the deadly H5N1 bird flu among geese and chicken in Liangying village of Chuzhou city. Qiao gained overnight fame as the first informer of a bird-flu outbreak. But his joy did not last long. One month later, Gaoyou police paid a midnight visit to Qiao's home and "invited" him to the station for a "chat", which turned out to be the prologue to detention. The next day, Qiao was arrested on suspected fraud and blackmail activities. His arrest happened 2 days after he attempted to report another bird flu outbreak -- this time in his own hometown. His arrest made headlines. Observers pointed out that the timing of Qiao's arrest suggested it was hardly coincidental. Many believed he was being framed. The Guangzhou-based and often outspoken South Metropolis News pointed out Qiao's arrest took place when he was preparing to expose the bird flu outbreak in Gaoyou. Qiao was tried on 21 and 26 Apr 2006. The court has yet to hand down a verdict. In China, it is rare for such a case to be tried twice without a court ruling. Analysts said it was likely that the central government intervened, so the case now seems to be moving to Qiao's advantage. Near the Jiangsu provincial capital Nanjing, Gaoyou abounds in geese and ducks. Poultry and eggs provide almost the entire gross domestic product (GDP) to Gaoyou. For the locals, an outbreak of bird flu there could mean the end of the world. To the local farmers, Qiao was just a "bad guy". Because of his tip-off, the government decided to destroy all reared poultry in the neighborhood, but the state compensation did not suffice to cover the colossal loss^ref.
• a 24 year old previously healthy female poultry worker who was four months pregnant in Zongyang County in Anhui Province developed fever, chills, and cough on 2 Nov 2005. Chickens and ducks in her household had become ill and had died during October. From October 25 through October 30, the patient had been actively involved in slaughtering and defeathering sick poultry before they were cooked for family consumption. She presented to the hospital in Tongling City, China, on November 7 with dyspnea, cyanosis, a temperature of 38.8°C, a pulse of 118 bpm, a RR of 37 bpm, and an O₂ saturation of 69%. Her white-cell count was 4050/ml, with a lymphocyte count of 608/ml. A chest radiograph showed bilateral diffuse infiltrates in the lower lobes. Her condition deteriorated despite treatment with azithromycin and cefotaxime. She required intubation that evening. The following day, her chest radiograph showed extensive infiltration of both lungs. Despite intensive supportive care, DIC and MOF developed, and she died on November 10. She tested positive for H₅N₁on Nov 16, similar to that of influenza A/duck/Fujian/1734/2005, a clade 2 virus^ref : 22 farmers who had close contact with the woman were all ok. Women in the second and third trimesters of pregnancy are at increased risk for complications of influenza and should be considered for vaccination^{ref1, ref2}
• a 35-year-old female farmer (surname : Xu) in Xiuning County in the eastern Anhui province (about 100 km (60 miles) northwest of Zongyang County) developed fever and pneumonia-like symptoms on Nov 11 after contact with sick and dead poultry, was hospitalized on 15 Nov 2005, died on Nov 22 and tested positive on Nov 24^ref.
Qiao Songju, a Chinese farmer, was arrested in November 2005. Detained for 2 weeks, he has been denied contact with his lawyer. His wife fears that Qiao was arrested for reporting an avian-influenza outbreak in Anhui province 8 weeks ago.
• a 26-year-old female farmer (surnamed Wang) from Yingshang County had contact with sick and dead poultry in her neighborhood, developed fever and pneumonia symptoms on Feb. 11, 2006 and tested positive for H₅N₁ by both the Anhui provincial CDC and the national CDC. He recovered and was discharged on Mar 23^ref. inspection teams from the Ministry of Agriculture and the provincial agricultural authorities found 13 chickens died in Jitai Village on Feb. 22. H₅N₁ virus were isolated from samples of 4 dead chickens by the national bird flu reference laboratory on Sat Feb 25. The local government has culled > 200 fowls in the area and intensified prevention measures. Those having close contacts with Wang have been put under medical observation by local health authorities : so far, no abnormal symptoms have been reported^{ref1, ref2}
• Hunan province (also famous in China as Mao Zedong's birthplace) : since Oct 22 another outbreak affected 687 and killed 545 chickens and ducks in the village of Wantang^ref, Xiangtan County (near the provincial capital, Changsha) on Sat Oct 22, was confirmed Tue Oct 25, and prompted authorities to destroy 2,487 others. In response to the outbreak, 43 750 avians have been vaccinated with an inactivated mono H₅N₂ vaccine^ref. Veterinary staff and villagers celebrated the end of the quarantine by burning their protective suits and warning banners that had been used to cordoned off the area. The live poultry markets in a 10 km radius from the affected region were also allowed to reopen.
• 12-years old He Yin, native of Wantang fell ill after the family ate a chicken out of 2 dozens chickens and duchs that died of an unspecified disease on Oct 6 : the girl became ill on 11 (10?) Oct 2005 with a fever and coughing and died on Oct 17 (13 ?)  in the intensive care unit of the children's hospital in Changsha, the provincial capital, but tested negative for bird flu on Oct 27, but further tests were positive forH₅N₁. No abnormal signs were detected in 152 villagers who came in contact with the 9 year old boy or his 12 year old sister, including the father (He Tieguang)
• her 9-year-old brother He Junyao, who started showing flu-like symptoms only after the sister's death, was hospitalized with respiratory symptoms on 17 Oct 2005, was quarantined in the same hospital on Oct 27, fully recovered, and was discharged on Nov 12. He tested negative in initial antibody tests, but tested positive for H₅N₁ on Nov 15 [the 1st admission of a human bird flu infection on the mainland : anyway readers are reminded of the H₅N₁ infection confirmed in a 9 year old boy and his 33 year old father who had returned from Fujian Province to Hong Kong in February 2003. The boy survived, his father died and his 12 year old sister had died of an undiagnosed respiratory illness in Fujian prior to their return to Hong Kong.  At that time, the source of infection was speculated to be in Fujian province where the family had been visiting, but it was never confirmed] : Hunan Provincial Children's Hospital Zhu Yimin will arrange regular checkups for the boy until he is 18 years old^ref. The poor farmer spent > 10,000 yuan (US$1,200) on his children's treatment; and the hospital said he still owed 6,000 yuan (US$740)
• a 36-years old middle school teacher, who lived in a different part of the county, injured his hand while cutting raw chicken meat before falling ill and has since recovered : she tested negative. What may hamper investigations is that the 12-year-old girl's body has been cremated, but samples taken before cremation can still be studied and so can the other 2 victims.
On 18 Nov 2005 an outbreak in Laobutou village, Yongzhou city affected 456 birds causing 402 deaths and 5608 slaughtered^ref.
• a 12-year-old Chinese girl from rural Hunan developed a fever, sore throat, and cough on Oct 8 and died 9 days later. She tested positive on Dec 19.
• her 9-year-old brother developed fever and a cough on Oct 10 but responded to antiviral treatment in hospital. He was discharged on November 12 and has remained symptom-free.
The researchers found that the children's close contacts, totalling 191 people, were all healthy. The family had 22 chickens and ducks kept in cages within the house close to the bathroom and toilets. Between October 6 and October 12, up to 6 birds were dying each day.
• a 6-year-old boy (surnamed Ouyang) from Guiyang county in the central province of Hunan developed symptoms of fever and pneumonia on 24 Dec 2005, tested positive on Jan 9, 2006 and was transferred to Hunan Provincial Children's Hospital on Jan 11 : he recovered and was discharged on Feb 23 : Hunan Provincial Children's Hospital Zhu Yimin will arrange regular checkups for the boy until he is 18 years old^{ref1, ref2}. Poultry at the boy's home died before he fell ill. The earlier Hunan case, which was one of the 1st 2 reported in China in mid-November 2005, lived around 300 kilometres away from the present case^ref.
• a 20-year-old female farmer developed symptoms on 27 Jan 2006 and was subsequently hospitalized with severe pneumonia. Symptom onset followed the culling of poultry raised by her household. She died on 4 Feb 2006^{ref1, ref2}
• Liaoning province : since Nov 3 2005, H₅ subtype AI was detected in an outbreak^ref in chickens, > 20 magpies and other kinds of wild birds died since Oct 26 in Gongtai village, Badaohao town of Heishan county, Jinzhou city and Fuxin city^{ref1, ref2} : 8940 chickens died, 6,000,000 domestic birds were culled and another 13.9 million vaccinated. Heishan County lies around 300 km northeast of Beijing and is on the migratory bird route from East Asia to Australia. Birds first started flocking into Liaoning in mid-October 2005. Most come from Siberia and usually stay in Liaoning for 1-2 weeks : birds will leave at the end of this month when the temperature plummets below 0°C. On Sat 12 Nov 2005, the Liaoning Provincial Control Office of HPAI ruled out 6 suspected HPAI outbreaks in this northeast China province : the office has erased Nanwa Village in Xinmin City of Shenyang, Jintun Village of Jinzhou City, Bajiazi Village of Jinzhou, Guojia Village of Jinzhou, the Beizhen Street of Beining City in Jinzhou and Yujiatun Village of Heishan County from the bird flu blacklist. According to Avibase, the denomination "magpie" is used for 6 species of Chinese birds belonging to the family Corvidae, in addition to the common Eurasian magpie (Pica pica). The other species are: azure-winged magpie (Cyanopica cyana), gold-billed magpie (Urocissa flavirostris), blue magpie (Urocissa erythrorhyncha), white-winged magpie (Urocissa whiteheadi), green magpie (Cissa chinensis), and yellow-breasted magpie (Cissa hypoleuca). There are 3 species of magpie that are actually found in Liaoning

Province (the area of one outbreak in NE China).
• the Eurasian magpie Pica pica;
• the Asian azure-winged magpie Cyanopica cyanus;
• the red-billed blue magpie Urocissa erythrorhyncha.
All 3 species are largely resident, though there might be some local dispersal (esp. in autumn). The Eurasian Magpie is an abundant bird, found around villages, towns, anywhere with disturbed habitat. They are omnivores, and very fond of scavenging around farms etc. Considered a lucky omen generally, they are not often persecuted.  It is also apparently the only wild bird species that was found dead in South Korea after the outbreak here (2003/2004), resumably after eating infected poultry or waste. Asian Azure-wingeds are rather more local, and again are often found around villages and farms. They are also omnivores, but very often feed largely on fruits and seeds (at least here in South Korea). The Red-billed Blue Magpie is a common bird of "forest edge, scrub and even villages" (Mackinnon and  Phillipps, A Field Guide to the Birds of China, OUP, 2000).
Accurate identification of the "magpies" reportedly affected by H₅N₁ in the current outbreak might be useful in evaluating their respective role in the spread of the virus. 116 people were quarantined.  About 1100 chickens were killed in the latest 2 outbreaks in Beining^ref, Jinzhaou city, and Fuxin, which were reported to the provincial health authorities on 6 Nov 2005. 198 million chickens have been vaccinated in the said province in response to the outbreak. 3 vaccines have been applied^ref :
• inactivated mono H₅N₂ vaccine
• inactivated recombinant H₅N₁ vaccine
• live recombinant avian pox virus vectored H₅ vaccine
The quantities of each vaccine were not specified.
The 9 plants officially certified by the authorities to produce AI vaccines as of November 2005 :
• manufacturer: Harbin Veterinary Research Institute, Harbin. [alternative URL]. Affiliation: Harbin Veterinary Research Institute. Types of Vaccines:
• inactivated mono H₅N₂ vaccine;
• inactivated recombinant H₅N₁ vaccine [This is probably the reverse genetic produced influenza A inactivated vaccine, described in 20050210.0456 and 20050307.0680];
• live recombinant avian pox virus vectored H₅ vaccine (For chickens only).  [See 20050210.0456 and 20050307.0680].
• manufacturer:  Zhengzhou Bio-pharm Co., Ltd., Zhengzhou city, Henan Province. Affiliation: China Animal Husbandry Group (CAHG). Type of Vaccine: Inactivated mono H₅N₂ Vaccine.
• manufacturer: Qingdao Yebio Bioengineering Co., Ltd, Qingdao City, Shandong Province. Affiliation: the National Animal Quarantine Institute of the Ministry of Agriculture. Type of Vaccine:
• inactivated mono H₅N₂ Vaccine;
• inactivated Vaccine of Avian Influenza (H₉ Subtype);
• bivalent Inactivated Vaccine of Avian Influenza (H₅N₂) and Avian Influenza (H9).
• manufacturer: Guangdong Yongshun Bio-pharm Co., Ltd (Former Guangdong Bio-pharm Co.), Guangdong Province. Type of Vaccine: Inactivated mono H₅N₂ Vaccine.
• manufacturer: Zhaoqing Dahua agriculture Bio-Pharm Co., Ltd, Zhaoqing City, Guangdong. Affiliation: Veterinary College of Southern China Agriculture University. Type of Vaccine: Inactivated mono H₅N₂ Vaccine.
• manufacturer: Liaoning Yikang Bioengineering Co., Ltd, Liaoyang City, Liaoning Province. Type of Vaccine: Inactivated mono H₅N₂ Vaccine.
• manufacturer: Nanjing Merial Animal products Co., Ltd. Affiliation: China Animal Husbandry Group (CAHG). Location: Nanjing City, Jiangsu Province. Type of Vaccine: Inactivated mono H₅N₂ Vaccine.
• manufacturer: Qilu Animal Health Products Factory, Ji'nan City, Shandong Province. Type of Vaccine: Inactivated mono H₅N₂ Vaccine.
• manufacturer: Chengdu Jianghua Bioproducts Co., Ltd. Affiliation:  Jianghua Group. Location: Ziyang City, Sichuan Province. Type of Vaccine: Inactivated mono H₅N₂ Vaccine.
The use of live AI virus vaccines in poultry is a very risky proposition, especially for H₅ and H₇ subtypes, and is in theory strongly discouraged; mutations of low-pathogenicity (LP) AI field viruses to high pathogenicity (HP) have been well documented in several countries. However, with the advent of reverse genetics, changes in one or more genes may result in the creation of a live AI virus with reduced potential for mutation to HP. Furthermore, a cold-adapted AI virus may be produced by selection of virus strains at lower temperature. However, such viruses would need extensive safety testing for reversion before accepting them as safe to apply in the field. Any vaccine -- before use -- must be thoroughly investigated by the "competent authority" of a country's government to determine its safety, purity, and potency. After the principal approval of a vaccine type, it remains the responsibility of the authority to supervise and monitor the control upon the production, testing, distribution and application of each batch. It would be reassuring to have confirmation that all batches of AI vaccines undergo such procedures.
A 31-year-old female chicken farmer in Fangshan Town in Heishan county (which was hit by bird flu on Nov. 3 and declared free from the epidemic on December 1) fell ill on 30 Oct 2005 following contact with dead birds with high fever (38°C). Then her condition worsened with more flu symptoms like coughs and shortness of breath on Nov. 3. She suffered from severe pneumonia and acute respiratory distress on Nov. 7, about one week after falling sick. Following treatment at a hospital, the woman recovered and was discharged on 29 Oct 2005, after no flu symptoms had been detected for 14 consecutive days. During treatment, Liaoning Provincial Disease Prevention and Control Center tested her blood four times - in the acute period, at 14 days, at 21 days after she got sick, and 28 days after she got sick and was recovering. The previous three tests were negative, while the last one was positive. The outcome was confirmed in further tests by the China Disease Prevention and Control Center. The local disease control and prevention center found the blood sample on Nov. 26 positive, namely 28 days after the woman got sick. The sample was forwarded to the China National Disease Prevention and Control Center, which found it negative. But antibody testing using a microneutralization test on Dec. 5 with local H₅N₁ bird flu virus from Heishan was positive and confirmed her as China's 5th human case of AI H₅N₁. The information was sent to a local disease control and prevention center and publicized in the following 2 days. 9 people in close contact with Liu, including her husband, son, daughter, mother-in-law, a village doctor and four county medical workers, showed no flu-like symptoms after having been observed for 7 days^ref. Using this test, a positive diagnosis is made when antibody levels in a blood sample taken late in illness are at least 4 times higher than those found in a sample taken early in illness. Diagnostic confirmation using antibody tests, though reliable, is thus slower than that achieved using direct tests for virus RNA^ref.
• Hubei province : on Nov 13 2005 a fresh outbreak of H₅N₁ virus killed 3500 birds (and other 3800 culled) in Swan economic developing area, Shishou city, HPAI H₅N₁ virus was found in dead fowl sent from some family farms in Zepu Country and Urumqi County, both in southern Xinjiang : in the 2 bird-flu-hit counties, a total of 322 500 family birds within a radius of 3 km have been culled. In a picture titled "Chinese health workers cull chicken in Zepu County, north west China's Xinjiang Ugyur Autonomous Region in this photo taken on 12 Nov 2005," the workers are dressed in protection gear, including facial masks. However, eyes remained unprotected^ref.
• Ningxia autonomous region : since 17 Nov 2005 an outbreak in Shangqian Cheng village, Yinchuan city, killed 230 birds (other 900 culled).
• Xinjiang Uygur autonomous region :
• since 15 Nov 2005 an outbreak in Niuzhuangzi village, Miquan city, killed 2064 birds (other 4056 culled).
• around Urumchi, the regional capital :
• since 16 Nov 2005 an outbreak in Daban Cheng village, Urumchi city, killed 38 birds (other 87 destroyed)
• since 12 Nov 2005 another outbreak killed 8 birds and destroyed 48 in Wulabo village
• on Nov 24 300 fouls died (380 slaughtered) in Biesituobie village, Xinyuan County. Local authorities culled 118,153 poultry within 3 km (2 miles) of the affected area to contain spread^ref
• since Nov 22 288 deaths (512 slaughtered) in Shanshan county^ref
• Yunnan province : since 17 Nov 2005 an outbreak in Hehua village, Chuxiong city, killed 2500 birds (other 8500 culled).
• Jiangxi province :
• a 35-year-old peddler man surnamed Guo in Suichuan County of Jiangxi Province, east China, fell ill with fever and pneumonia symptoms on December 4,  died on Dec 16, 2005 and tested positive for H₅N₁ on Jan 11^ref. A new avian influenza case [a 7th case?] had been confirmed in the patient's village following the death of 1640 ducks raised by a fellow villager^ref
• Sichuan province :
• a 35-year-old woman (surnamed Wei) from Zhoujiaxiang village in Sichuan province developed symptoms on Jan 3, was hospitalised Jan 10 with fever and pneumonia and died on Jan 11, 2006 and tested positive for H₅N₁ on Jan 12. The woman was a poultry slaughterer. Between Dec 25, 2005 and Jan 5, 2006, poultry in 8 other households in Wei's neighbourhood had fallen sick and died, though it is unknwon if they had succumbed to the H₅N₁. People who had come in contact with the woman have been put under observation by local health authorities. So far, they have reported no abnormal symptoms^{ref1, ref2}. No outbreak of the disease among poultry had been reported in Jianyang city, with the closest H₅N₁ outbreak recorded in Sichuan's Dazhu county 245 km (150 miles) east^ref.
• a 29-year old woman (surnamed Cao) who ran a shop in a farm goods market in Jinhua town, close to the province capital Chengdu, developed fever on 12 Jan 2006, was hospitalized with symptoms of pneumonia, tested positive for H₅N₁ on Jan 23 :  her condition deteriorated rapidly, and she died on 23 Jan 2006. She was self-employed in a shop selling dry goods. No information on possible exposure to diseased birds as the source of her infection is presently available, but an investigation is underway. Close contacts have been placed under medical observation^ref
• an 8 year old girl (surnamed Sun) from Suining developed symptoms of fever and pneumonia on 16 Apr 2006 and tested positive for H₅N₁. She remains in hospital as of Apr 27 : poultry deaths recently occurred near the child's home^{ref1, ref2}
• Guanxi province :
• a 10-year-old girl student (surnamed Tang) in Ziyuan County in the southern Chinese province of Guangxi developed symptoms of fever and cough on Nov. 23, followed by pneumonia, died on Dec 7, 2005 and tested positive for H₅N₁ on Jan 11^ref
• Fujian province :
• a 41-year-old female factory worker (surnamed Zhou) from southern Fujian province showed symptoms of fever and pneumonia on Dec 6, was hospitalized on Dec 8, died in Sanming city on Wed 21 Dec 2005. On 13 Dec 2005, initial laboratory tests on samples from the patient tested negative for H₅N₁ virus. But further tests on 23 Dec 2005 -- including PCR tests carried out at the Chinese Center for Disease Control in Beijing -- showed positive results, reported on Dec 29. The virus was also isolated from the patient. Close contacts who have been placed under medical observation have not displayed any symptoms, health authorities report. All 66,172 poultry raised within 3 km of Zhou's home had been vaccinated by Dec 5. Investigators tested and culled 230 birds near Zhou's home after the infection was confirmed, but found no infections. Investigators have not been able to confirm any direct contact between the patient and poultry prior to the onset of illness. Zhou was already weak after an operation to remove a tumour in mid-October. This 7th Chinese case (and 3rd death) is the 1st human case of H₅N₁ avian influenza reported from the southern province of Fujian. In accordance with recent precedent, it is likely that the diagnosis will be accepted by WHO without referral to a reference laboratory. It should be remembered that Hong Kong health officials reported 2 confirmed cases of H₅N₁ (one of them fatal) from 2 members of a family of Hong Kong residents following their return from a visit to Fujian province in February 2003 (a 33-year-old man and his 9-year-old son; the father died). A possible additional fatal case may have occurred in a 3rd family member (8-year-old daughter) who reportedly died while the family was in Fujian on 4 Feb 2003 of unidentified causes after exhibiting symptoms of "acute febrile infection with cough."
• a 26-year-old female farmer (surnamed Lin) from Zhangpu county in the southern province was reported as infected with bird flu on Feb 8, 2006 after being hospitalised with fever and pneumonia on January 10. After medical treatment, the patient's condition is currently stable. Like most of the other human cases detected in China, no outbreak among animals was detected in Zhangpu county where Lin lived (319 poultry samples collected within a 3-km (1.8-mile) radius of Lin's home tested negative), emphasising the extent of the problem in the country and the inability of authorities to effectively monitor the disease. She was highly likely to have had contact with sick animals^{ref1, ref2}
• a 6-year-old bird flu victim had been released from a hospital after fully recovering^ref
• Shanxi province : since 10 Nov 2005 an outbreak in Gaoyang village, Xiaoyi city, killed 8103 birds (other 1283 culled). On Feb 8, 2006, the Chinese Ministry of Agriculture reported another AI outbreak in a large poultry farm in northern China's Shanxi province^ref, with 15,000 chickens dying from the virus in 2 days last week : it is already under control (187,745 chickens culled). The previous outbreak was reported on 10 Jan 2006 in the southern province of Guizhou, although human fatalities have since been recorded in areas where the virus was not detected^{ref1, ref2}. On Feb 10, 2006, 35 workers were confined to their homes in Yangquan city and were receiving twice-daily medical check-ups^ref.
• Zhejiang province^ref : one of the smallest of the Chinese provinces, it includes the southern half of the populous Yangtze River delta in the north; a complex of rugged mountain ranges, with heights of more than 1900 m (6200 ft) in places, in the south; and the offshore islands of the Zhoushan Archipelago, situated at the entrance to Hangzhou Bay. Rice and silk are important lowland crops, with tea a major product in upland areas
• a 9-year-old girl (surnamed You) from Anji County visited relatives twice in Guangde County of Anhui Province : during her visits, chickens raised at her relatives' homes got sick and some died. She developed symptoms of fever and pneumonia on Feb. 10, 2006, was hospitalized. She died on Mon Mar 6, 2006^{ref1, ref2}. You's samples tested H₅N₁ positive by both the Zhejiang provincial center for disease control and prevention (CDC) and China's national CDC : those having close contacts with You have been put under medical observation by local health authorities. So far, no abnormal symptoms have been reported^{ref1, ref2, ref3}.
• Guangdong province^ref :
• a 32-year-old man (Lao Qiliang) (unemployed) in the southern city of Guangzhou developed fever and pneumonia on Feb 22 and died on Thu Feb Mar 2, 2006^{ref1, ref2, ref3, ref4}. Hong Kong is < 2 hours from Guangzhou, the capital of Guangdong, by train, and the flow of travellers between the 2 cities is heavy. Although Hong Kong has been free from human cases of the H₅N₁ bird flu virus since early 2003, the city continues to screen the temperatures of people entering the city at immigration. No outbreaks in poultry have been reported in Guangdong Province since 2004. The newly confirmed case is the 1st human case reported from Guangdong Province^ref
• a 41-year-old female identified as Ms Li, who lived in the Xihua area of Yuexiu district and worked as a vegetable-sellerat a market in Guangzhou, capital of Guangdong province, was admitted on March 25 at Guangzhou No1 People's Hospital  with a cough, fever and headache, and tested positive on Mar 27. The case was reported on 30 Mar 2006 to the WHO's Beijing office. The woman worked in an area 20 m from where live poultry were sold, so she's being treated with caution. She has been given a preliminary diagnosis of pneumonia of unknown origin since initial tests at WHO were negative. The woman was in stable condition and tests results could be released up to 5 weeks later^{ref1, ref2}
• a 9-year-old boy at the Guangzhou Children's Hospital was reported with a serious pneumonia on April 6
• a 31-year-old man (surnamed Jiang^ref) who worked as a truck driver in Shenzen^ref (mainlander or a Hong Konger residing in Shenzhen) developed back pain, fever, cough and pneumonia on 3 Jun 2006 after visiting a wet market in the city where live chickens were on sale, and on Jun 9 was hospitalized in a critical condition in a Shenzhen hospital, where he tested positive for H₅N₁ on June 15. Shenzhen is a large and fast-growing city in southern Guangdong province, just over the border from the Special Administrative Region of which Hong Kong is a part. Shenzhen is approximately 22 miles from Hong Kong and 100 miles from Guangzhou^ref. All 98 people who had close contact with Jiang tested negative for the disease on Thu 15 Jun 2006^{ref1, ref2}. The contacts included relatives of the 31-year-old male patient, medical workers in a local clinic and in Shenzhen People's Hospital, where the man had been treated, and the patients in the same ward. Tests on the 98 contacts all proved negative for the H₅N₁ strain of the bird flu virus, but doctors will continue observations of them. The man was still in critical condition and being treated in Donghu Hospital in the city. A test sample from him had been sent to Beijing for verification by the Ministry of Health. The patient was transferred to Donghu Hospital on Tue 13 Jun 2006 for advanced treatment. The Shenzhen city government has announced a 2nd-degree emergency as a precaution against bird flu in the city. The male patient, a truck driver, had no contacts with birds before becoming ill. However, his wife bought a freshly slaughtered chicken from a local market 2 weeks ago and cooked it for dinner for 5 family members, including the man. None of the man's family showed similar symptoms. They and other close contacts are under medical observation. The confirmation of this 19th human case in an area where apparently no outbreak of disease in poultry has been reported prior to discovery of this human case suggests that surveillance of animal disease may have been inadequate. However, it is possible that the patient's occupation as a truck driver exposed him to infection at another locality. It is reassuring to learn that there has been no indication of transmissibility of the avian virus either among close relatives or unrelated contacts^ref. On Jun 21 X-rays showed the shadow on the patient's lungs had diminished, but he was still critically ill^ref. On Jul 5, 2006, after 20, days in hospital, the man's respiratory functions had improved, and he was reading, writing and listening to music. His condition had improved to stable, but he still needed time to recover completely : he should be able to breath without the use of a respirator in a week^ref
• Shanghai province (economic hub of 17 million people)
• a 29-year-old woman (surnamed Li), a migrant worker, showed symptoms of fever and pneumonia on March 13, went to hospital for the first time in Shanghai on Mar 15, died on Tue Mar 21 and tested positive on Mar 23. Doctors and nurses who tended the patient were under quarantine. No poultry outbreaks have been reported in the Shanghai area since Feb 2004^{ref1, ref2, ref3, ref4, ref5}
• Hubei province :
• a 21-year-old man migrant worker who worked as a security guard in the large industrial central city of Wuhan started showing symptoms on 1 Apr 2006, was diagnosed with H₅N₁ strain on Mon 17 Apr 2006, and died on Wed 19 Apr 2006^ref. No poultry outbreaks have been reported in Hubei Province since November 2005. His close contacts have been placed under medical observation^{ref1, ref2, ref3}
The outbreaks reported here^ref literally span the width and breadth of China.  The 3 outbreaks in Xinjiang autonomous region are located north of Tibet, as far west as you can go in Chinese territory.  The outbreak in Yunnan is in south-central China bordering Burma and Viet Nam.  Hubei and Shanxi provinces are right in the middle of China.  If you add this wide swath of geography to previous reports from Liaoning province in the extreme Northeast, then you have pretty well covered all of China^ref.
On October 14, 2005 Taiwan central Taichung harbour coast guard intercepted a Panama-registered cargo ship from the southeast Chinese city of Fuzhou (capital of Fujian province, southeast China) prior to landing and found 1037 smuggled birds of 19 species (276 dead), mice and turtles. This consignment included pet birds : hill myna is a starling, Gracula religiosa, family: Sturnidae, order: Passeriformes, native to Europe and North America. It has the capacity to mimic human speech and often kept as a pet. Red-billed leiothrix (Chinese nightingales), Leiothrix lutea, family: Timaliidae, order: Passeriformes, is a babbler, native to Southern Asia.  The black-naped oriole, Oriolus chinensis chinensis, order:  Passeriformes, family: Corvidae, is a songbird, native to India, southeast Asia and China. It will be interesting to note which of the said species was found infected and whether they were clinically affected or asymptomatic. The smuggled animals were destroyed the next day and on Oct 20 tests showed all 8 of the sampled birds were avian flu H₅N₁⁺. At the time of the operation, a total of 25 people were on board; 24 of them left the country on the same ship on 16 Oct 2005. One crew member from the ship, a Chinese national, was held in quarantine in the Taichung Detention Center on the charge of smuggling and was interrogated : he had no symptoms but was treated with oseltamivir. The remaining 24 crew members left Taiwan with the ship on Mon Oct 17. A 40-person team that searched the ship and destroyed the birds was not quarantined, as team members had worn protective gear and did not come in direct contact with the infected birds, but they are being monitored as a precaution. It was the 2nd time Taiwan has seized birds smuggled from mainland China since the coast guard launched a crackdown on the illegal trade in August 2005. Smugglers face up to 3 years imprisonment and a TWD 150 000 [USD 4400] fine. Officials are considering tightening the smuggling law. In December 2003, the Taiwan authorities destroyed 6 smuggled ducks which were found on the water near Taiwan's front-line island of Quemoy. Reportedly, the ducks were found infected with the H₅N₁ virus that hit Hong Kong in 1997. Could it be assumed that a previous consignment of birds smuggled from China, confiscated after August 2005, was tested and not found positive? The authorities offered up to 3.6 million Taiwan dollars (USD 107 462) for tip-offs on bird smuggling. Smuggling is rampant between Taiwan and the Chinese mainland, which are separated by the Taiwan Strait, 170 km wide at its most narrow point. Though members of the Anseriformes order (particularly the Anatidae family, to which swans belong) have been traditionally considered as the main reservoir and vectors of avian influenza viruses, the role of Passeriformes should be studied as well. BAPHIQ said that it has destroyed 81.68 tons of animal products smuggled from abroad in 2005 as well as 5146 animals, including 5070 birds. Genetic characterization of the H₅N₁ virus isolated from this incident showed that it shared 96% homology with the virus derived from yet another smuggled consignment of ducks in Kinmen (just offshore of the Fujian province of China, but governed by Taiwan) from China during the 2003 SARS period; (4) the virus isolated shares 99% homology with the H₅N₁ virus currently circulating in Fujian; and (5) H₅N₁ virus was found in Japan in a shipment of frozen duck meat from Shandong province of China in 2003.
Seroprevalence ("presumptive antibody detected by single radial hemolysis using antigenic material from avian virus only") of 13 HA subtypes (H₁ to H₁₃) in 4 human populations. H₅antibodies were detected in 2% of samples from the Pearl River Delta (n=400), 7% of samples from Jiangsu Province (n=300), 2% of samples from Taichung, Taiwan (n=150), and nearly 0% of samples from Urban Hong Kong (n=100); the seropositivity of human sera for H₇, H₉, H₁₀ and H₁₁ viruses was estimated to be as high as 38, 33.5, 17 and 15% respectively. There are no corresponding data reported for N subtypes^ref, so a conclusion that these antibodies indicate prior presence of H₅N₁ in the human population is unfounded, and there is no support for an estimate of 35 million Chinese citizens with H₅N₁ antibodies^ref (but H₅N₁ is the only H₅ virus known to infect humans !). Though the number of people involved is large, it accounts for only about < 2.9% of the entire Chinese population. From the serum surveillance reports posted in recent years, it's a fair percentage for poultry workers, but in the general population, the antibody level to H₅ strains only amounts to 0.48% in Wuxi City and 0.75% in Shanghai. This same paper reports the results of a study of ducks (8737), geese (1353), and chickens (1708) originating from southern China and Hong Kong over a 5-year period (Nov 1975-Oct 1980) at a poultry-dressing plant in Hong Kong.  Of 586 viral isolates obtained from this survey, 23 had HA subtype H₅: 22 of these isolates were H₅N₃ (one from a goose, and 21 from ducks), and one isolate was H₅N₂ (from a duck). No H₅N₁ virus was found.
There are suitable receptors for AIV in the human eye, and based on analogies with other ocular viruses sharing the same receptor specificity, the eye may be a portal of entry for avian influenza virus^ref. The prevalence of antibodies to avian influenza viruses, including H₅, in the Chinese population is striking. Significantly there have been no confirmed human cases of avian H₅N₁ influenza in China during the current outbreak in the area. If this situation is mirrored throughout the other H₅-affected countries in East Asia, it might explain the apparent absence of disease among workers in the poultry-rearing and processing industries in the region, and among those involved in culling diseased poultry (the single confirmed case of H₅ infection of a poultry worker appears to be an asymptomatic case in Indonesia, diagnosed retrospectively). It may be that workers in the poultry industry are protected by their pre-exposure to avian influenza viruses (and inadvertent immunization), in contrast to those in domestic situations handling diseased birds without prior exposure to avian influenza viruses
Xianghai National Nature Reserve, a major habitat of migratory birds in north east China's Jilin Province, has closed off all of its scenic spots on 12 Nov 2005 to prevent tourists from being exposed to avianborne diseases. Jilin -- adjacent to bird-flu-hit Liaoning Province and the Inner Mongolia Autonomous Region -- has strengthened inspection and quarantine to keep the disease out of the province. The wetland reserve of Xianghai, the Momoge Nature Reserve in the province, and Zhalong Nature Reserve in Jilin's neighbouring Heilongjiang Province are the 3 major protection areas for cranes. Xianghai, the home of 253 kinds of rare birds including some 60 red-crowned cranes, is on the flight route of migratory birds, which increases the province's risk of bird flu outbreaks. Groups of migratory birds have been flying south over the wetland these days : the reserve administration has taken measures to strengthen surveillance of the
birds. The birds living in the reserve (wild birds, or domestic birds maintained within the reserve?) have been injected with anti-bird flu vaccines : 10 observation stations and a 60 person surveillance team have been set up, carrying out round-the-clock watch on the birds.
It has been indicated recently that there are suitable receptors for avian influenza virus in the human eye, and based on analogies with other ocular viruses sharing the same receptor specificity, it is suggested that the eye may be a portal of entry for avian influenza virus. The use of goggles by sanitary teams engaged in the control activities of HPAI in affected premises, initially prescribed during the 2003 outbreak in the Netherlands, is strongly recommended.
China's public health authorities will report daily occurrences of epidemics during the Beijing Olympiad to be held in August 2008^ref.
On Mon 7 Nov 2005, in compliance with the central government's measures against bird flu, Beijing has suspended poultry trading and culling in all its 168
markets, poultry feeding in downtown areas, and poultry imports from regions outside the national capital.
At the moment China has 5.2 billion birds (4 billion chickens and 1.2 billion ducks and geese) as livestock, while over the course of a year the nation produces 14 billion poultry : China would inject all of the nation's 5.2 billion chickens, geese, and ducks with a vaccine against bird flu, the largest single vaccination effort ever for any species. Bird vaccine has been widely available for several years. Costing merely 10 cents a dose and produced by a dozen manufacturers, it is nearly 100% effective. China's Agriculture Ministry said it was producing 100 million doses a day.
Dr. Masato Tashiro, a Japanese WHO consultant, believes that China has had 3,000 infected cases and 300 human deaths from avian influenza, including 7 cases caused by human-to-human transmission and is hiding the true extent of the disease from the rest of the world, according to reports on the Internet portals including "New Scientist" and "WorldNet daily". Dr. Masato Tashiro, Director of the WHO Collaborating Center on Influenza at the National Institute of Infectious Diseases, Tokyo, and head of the Department of Virology of the National Institute of Infectious Disease (Japan), astonished colleagues with this information during a speech at a recent retirement dinner for a fellow virologist, Hans-Dieter Klenk, in Germany. Having just returned from the Hunan province of China on behalf of the World Health Organization (WHO), Dr. Masato Tashiro claimed that a reliable source had provided him with details of the true nature of the H₅N₁ virus in China. "We are systematically deceived," he is reported to have said. Tashiro visited China on behalf of the World Health Organization (WHO) in Hunan province. His laboratory, at the National Institute for Infection Research in Tokyo, as one of the Asian points of contact for the United Nations, had been particularly entrusted with investigations into avian influenza in Asia and China. Dr. Masato gave his lecture in the University of Marburg Clinic before some the most outstanding virologists in the world and shocked the meeting with his unauthorized data report from inside China. The Japanese virologist said he firmly believes in the reliability of the source and its data. The secrecy of the Peking government is still causing concern as it was at the beginning of the SARS epidemic disease, complained Tashiro. At least 5 medical co-workers who should be reporting on the situation in the provinces were arrested, and other publication-willing researchers were threatened with punishments^ref. Actually Dr. Masato was not there that time, despite he had have visited there before, and was not a member of the WHO mission this time. As an example of unauthorized information, he showed a slide which he received from a private source. This indicates > 200 deaths distributed in several provinces. The information he received indicated some human-to-human transmission cases, although details were not clear.
On Nov 29 2005 U.S.-based Chinese-language news portal Boxun listed the names and addresses of 77 workers brought in to help control rampant H₅N₁ outbreaks in poultry in Liaoning province in November have died of the virus, listing 14 names. Boxun reported the extent of the outbreak in wild birds at Qinghai Lake in central China in May, and alleged then that 120 people had been put in stringent hospital isolation in a nearby town, possibly with bird flu.
On 30 Nov 2005 9 officials of the Jinyu Group, a company based in Inner Mongolia that produces medicines, and of the Inner Mongolian Biological Medical Products Factory have been arrested for selling fake bird flu vaccines and are suspected to have contributed to an outbreak of the disease in northeastern China's Liaoning province : the 2 companies had manufactured and sold 200 000 vials of 12 different kinds of bird flu vaccine nationwide. With 29 outbreaks of the disease discovered so far this year, China is seeking to vaccinate its estimated 5.2 billion farm-raised birds, but requires manufacturers to have a license to produce the vaccines. Police said that the Jinyu Corporation failed to apply for a license from the state to manufacture bird flu vaccines for poultry, but
labelled its products with fake government licensing numbers. Investigators found the fake vaccines were used on farms in Liaoning's Jinzhou region, where an outbreak of bird flu occurred in mid-October 2005. Some 2.5 million farm raised birds were culled in the Jinzhou region following the outbreak, devastating the livelihood of farmers in the region. The relationship between the 2 suspected companies was not immediately clear, but one man arrested, Wang Jiafu, was a vice director of the Jinyu Corporation as well as the legal representative of the Inner Mongolian Biological Medical Products Factory. The practice, apparently related to the higher prices (and more laborious application mode?) of licensed vaccines, has been ongoing for an extended period.
Shangai agriculture and health departments have built a database about 20,000 people who work in the city's poultry industry in jobs like poultry production, transport, trade and processing^ref.
Significant observations in the WHO news conference of Dec 23 on China's response to AI by Dr Shigeru Omi, WHO regional director for the Western Pacific Region, are the following^ref :
• from the > 30 reported (Chinese) outbreaks in animals in 2005, no viruses have been made available (to international labs) so far
• the front lines of the battle against avian influenza are at the grassroots level.  It is here that some 70% of China's estimated 14 billion poultry are spread across backyard farms -- and from here that the 6 confirmed human cases have come from
• of the 6 confirmed human cases so far, 5 were not forewarned by reports of poultry outbreaks in the local community.
The Agriculture Ministry has warned that the risk of the virus spreading could be higher during the Chinese Lunar New Year, which falls at the end of Jan 2006, as meat consumption and the transport of live poultry increases. China's poultry industry, which state media says lost 60 billion yuan (USD 7.44 billion at USD 1 = 8.062 Yuan) alone in the 4th quarter of 2005, is gearing up for more losses, according to one senior official. Prices of chicks have fallen 80%, and the price of chicken in the markets is down 20%. Less severe poultry outbreaks in 2004 cost the industry an estimated 30 billion yuan (USD 4 billion), and the final figure for 2005 was likely to be far higher.
Most of China's human bird flu cases were not treated with oseltamivir, either because it was not available quickly enough to be effective or because the cases were not identified soon enough^ref.
What we've seen in quite a number of other cases in China is that the Ministry of Agriculture has not been able to identify viruses in the animals in that area. But there certainly have been reports from the health authorities and patients themselves that animals in their areas have been dying and have been sick for some weeks prior to their onset of their illness.
China culled 22,571,200 fowls in 2005 to curb bird flu : in 2005 about 163,100 fowls were found to have infected the H₅N₁ virus, 154,600 of which died of the pandemic. In 2005 China reported 31 HPAI outbreaks in poultry and 1 in migratory birds, with most appearing since October. The outbreaks hit 13 provinces and 32 counties, but all of them were effectively controlled without any large-scale virus spreading. Chinese farmers raised about 15 billion poultry in 2005, or 21% of the world's total. Since the beginning of 2006, other outbreaks among poultry occurred : 36 outbreaks of bird flu since October 2005 :
• Sichuan province : between 22 and 25 Dec 2005, 1800 chickens and ducks died in 3 households in Yangjia Town's Liuyan village (Dazhu county) : since they tested positive for H₅N₁ on Jan 3 2006, 12,900 poultry in the region have been culled to try to contain the virus. Sales of poultry, eggs and related products at all its 54 live poultry markets have been banned in the county since Tue 3 Jan 2006 for 21 days. Blood tests of all the 16 people in close contact with the dead poultry have proved negative. Dazhu, some 400 km east of provincial capital Chengdu, is where migratory birds from North China such as white cranes stop before flying further south to spend winter. Although most migratory birds from the north have left Sichuan for the south, some remain and will not leave until Spring Festival, which starts on 29 Jan 2006. In May 2006 it was announced that 5 officials in Dazhu county in Sichuan province had been sacked for of dereliction of duty because they did not report and contain the local outbreak in time^ref.
• Guizhou province : about 16 000 quail died between 1 and 6 Jan 2006 at a farm in Guiyang city's Wudang area : they tested positive on 10 Jan. The local government's veterinarian department culled 42,000 quail at the infection site on 6 Jan 2006
• Shanxi Province : an outbreak of H₅N₁ was reported in Yijing Township, Yangquan City, on 7 Feb 2006, and 202 745 poultry have died/been culled. In accordance with the "Contingency Plan on High Pathogenic Avian Influenza", Ministry of Agriculture and Shanxi Provincal authorities have taken a series of measure including stamping out all the infected farms and disinfection of infected premises combined with the immediate vaccination of all affected poultry within a 3-km radius. On 19 Jun 2006 samples taken after the chickens died in Changzi county of Changzhi City tested positive for the H₅N₁ strain^ref
• Anhui Province : 13 chickens died in Yinshang County of Fuyang City^{ref1, ref2}
• Guangdong province : 6,000-9,000 chicks about 1 month old, which were among a group of > 11,000 chicks, died over several weeks in the city of Guangzhou from suspected Coccidia illness, but officials haven't ruled out bird flu as a cause^ref. On Feb 24, 2006 a duck farm in the Huadu District of the city registered 200 deaths due to Rimerella anatipestifer^ref
• Shandong province : on 18 Apr 2006 authorities have culled about 8000 chickens in a poultry farm in Laixi city^{ref1, ref2}, after 400 chickens died there last week. The South China Morning Post said the farmer, identified only by his surname Chen, was ordered by officials not to talk about the cull as "it was a state secret". He and his wife were given injections on Sunday, but they did not know what they were for^ref.
• Liaoning province : 2 birds living in the wild and found dead in northeast China were confirmed to be infected with H₅N₁ bird flu on Thu 20 Apr 2006. The provincial government has disinfected the region where the magpie and wild duck were found : Liaoning has never had outbreaks of bird flu. This statement disagrees with China's official notification of 3 Nov 2005 to the OIE regarding an outbreak of HPAI H₅ in Badahoao, Jinzaou city, Liaoning Province, where 8940 chickens as well as 20 magpies and other wild birds reportedly died^ref. The report also indicated that 13.9 million birds were vaccinated in the Liaoning province with a monovalent, inactivated H₅N₂ vaccine^ref
• Qinghai Province : a total of 1168 migratory birds had been found dead in Qinghai and Tibet by 1 Jun 2006. The disease was striking more species of birds than last year 2005^ref
• Gangcha County : a dead bar-headed goose was found carrying the deadly virus Sat 29 Apr 2006
• Yushu County, about 800 km (500 miles) from the provincial capital Xining : 17 bar-headed geese (Anser indicus) were found dead on a wetland on 23 Apr 2006. The number of dead wild birds had risen to 125 by Thu 4 May 2006, of which 123 were bar-headed geese. The place where the outbreak happened is a high and cold area, located more than 800 km away from Xining, the provincial capital, and Qinghai Lake, which is an important habitant of a vast number of migrant birds. Yushu County^ref, the nearest human residential area, is also more than 60 km away^ref. The bar-headed gooseis known to breed in Central Asia and migrate over the Himalayas to winter in the wetlands of India. Could the affected birds have recently returned from H₅N₁-affected areas in India?^ref
• Xinjiang Uygur Autonomous Region : on Jun 7, 2006, on a farm in Hetian/Hotan county^ref , 200 domestic poultry out of 637, all dying from the bird flu virus^{ref1, ref2}
• multiple outbreaks involving a large but unreported number of susceptible birds have occurred in Shanxi province in the following villages: Shijiazhuang, Nanchuanzhuang, Beili, Dongchang and Xixhang. The report does not break down the outbreaks by location but does indicate that over a million birds (1,470,000) were depopulated. There were 2600 cases and 2400 deaths, again with no breakdown by location.
• Almost a year after, new cases of flu among wild birds have been reported since late April 2006 near Qinghai Lake and in Yushu county, a remote nomadic region several hundred kilometres to the south of Qinghai Lake^ref. It has been revealed by bloggers that the Chinese government has been breeding bar-headed geese near Qinghai Lake^ref. The breeding farms have been part of an experimental program, since 2003, intended to domesticate the birds and to release some of them to repopulate wild stocks. Birds at Qinghai Lake, and bar-headed geese in particular, are thought to have been an important early source of H₅N₁ avian influenza infections in birds. News about the breeding farms raises the possibility that these farms, rather than unfarmed flocks, might have been major sites of H₅N₁ infection at Qinghai. If confirmed, the finding is important, as changing the breeding practice might help control the infection. Guan says he had heard rumors of the farming program when he submitted his paper^ref, but couldn't confirm them. There is no proof that China's breeding program caused the Qinghai outbreak, but it does raise questions. The cultivation of bar-headed geese increases the chance for these birds to mix with infected domestic poultry. China's official report on the Qinghai outbreak, dated 27 May 2005, notified the deaths of 519 migratory birds, including bar-headed geese (Anser indicus), great black-headed gulls (Larus ichthyaetus), brown-headed gulls (Larus brunnicephalus), ruddy shelducks (Tadorna ferruginea) and great cormorants (Phalacrocorax carbo). It further indicated that the source of infection was under investigation, adding that the site is an important rendezvous of migratory birds on one of their Asia-Europe routes. The Bar-headed goose (Anser indicus)^ref breeds in Central Asia and migrates over the Himalayas to winter in the wetlands of India, believed to be the highest flying bird, having been seen at up to 30,000 feet. It lays 3-8 eggs in a nest near mountain lakes. The Bar-headed Goose is often kept in captivity, from which it sometimes escapes. The wild population is declining due to over-hunting. The Qinghai H₅N₁ virus was found later involved in HPAI outbreaks and infections in wild birds in Asia, Europe and Africa. If indeed a breeding project was involved, its possible impacts on applied husbandry and genetic intervention upon the exceptional (clinical) susceptibility of the geese to the H₅N₁ virus deserve to be thoroughly investigated.
• on Wed May 24, 2006, new outbreaks in Tibet's Nagqu (Naqu) Prefecture^ref and Qinghai's Golog (Guoluo) Tibetan Autonomous Prefecture occurred on the same migratory route where another outbreak in Yushu of Qinghai was reported early in May. A total of 399 bar-headed geese and ruddy shelducks  have been found dead in the 2 areas^{ref1, ref2}. Golog prefecture is situated in southeast Qinghai, bordering Sichuan (south) and Gansu (east). Yushu is situated in south-central Qinghai province. Qinghai lake/bird island, the site of the mass mortality in wild birds in May 2005, is west of Xining, in northeast Qinghai^ref.
• H₅N₁ virus was found on June 29, 2006 in dead birds in Zhongwei city in the north western Ningxia Hui Autonomous Region^ref
The AP report from China said the government is setting up an avian flu surveillance system in the eastern province of Jiangsu to focus on wild birds. The system will consist of 100 monitoring stations staffed by 1,000 workers throughout the province. Experts estimate that about 3 million migratory birds will fly to Jiangsu in the Mar-Apr and that another 5 million birds will pass through^ref
Led by microbiologist Guan Yi from the University of Hong Kong, researchers collected 51,121 faecal and other samples from healthy-looking birds in live-poultry markets across 7 provinces in southern China from January 2004 to June 2005. The H₅N₁ virus was found in 1.8% of ducks, 1.9% of geese, 0.46% of minor poultry like pheasants and quail, and 0.26% of chickens^ref. The vaccines made in China at the Harbin Veterinary Institute conformed to international standards and were fully effective, but there are local companies in China that produce vaccines, and it's possible these don't have the efficacy of those made at Harbin^ref
China will supply bird flu virus samples to the WHO, said WHO official to Beijing on Tue Mar 21 2006. The first 20 samples will be delivered to WHO's laboratories in Japan, Hong Kong, Australia or the UK within a couple of weeks for them to develop vaccine and antiviral drugs^ref.
Total : 19 cases, 12 deaths
Web resources : Flu in China & Flu Information Centre (F.I.C.) : China influenza map report
• India^{ref1, ref2} : poultry population was 489 million in 2003, according to the latest livestock census released in January 2005, a USD 13.6 billion poultry industry. The southern Indian state of Andhra Pradesh had the highest number of poultry at 102.3 million. The poultry population increased 45% from 1997. Nandurbar district had 3.1 million poultry^ref. The country produced 45.2 billion eggs in the year to March 2005, placing it among the top-5 egg-producing nations in the world. The per-capita availability of eggs has gone up to 41 in the billion plus nation from 25 in 1990-91, when India opened up its socialistic economy to foreign competition. Safety measures instituted by the government to stop the outbreak of bird flu. These measures were put in place in January 2004, soon after the virus resurfaced in Asia: import of poultry and poultry-related products has been completely banned from infected countries; check posts and quarantine stations on borders with neighbouring countries have been set up; customs has been directed not to clear poultry or poultry products from foreign countries without getting it cleared from the quarantine department^ref.
• no single report of an avian flu outbreak from India has been documented since 2001.
• samples drawn in 2002 from 3 poultry farm workers in Kattangalathur, Tamil Nadu state, southern India, while routinely monitoring the human population for influenza antibodies tested positive for anti-H₅N₁ antibodies at the Indian Council of Medical Research (ICMR) referral laboratory at the King Institute of Preventive Medicine in Chennai. The samples were drawn. The 3 poultry workers have not had bird flu and are doing well. Results were then confirmed by the Centers for Disease Control and Prevention (CDC), Atlanta late in 2004. Virus isolation and sequencing has not been attempted in India, as there is a lack of such a secure bio-safety facility. Migratory birds that arrive on Tamil Nadu's coast in Vedanthangal Bird Sanctuary, north of Chennai, every year could be a source for the virus strain. Poultry is a major state industry for the area, and migratory birds arrive every year on Tamil Nadu's coast in Vedanthangal, north of Chennai. Therefore, it is rather puzzling that 3 people were infected with the HPAI H₅N₁ while working in the poultry farm(s), but that no sick or dead birds were ever discovered or reported by the local or national health authorities, such as ICMR.
• > 10,000 poultry died in nearly 20 villages of northeastern Assam's Dhubri district bordering Bangladesh since Jan 31 to Feb 8 2004. Neither Burma nor Tibet, the Chinese province bordering India, have so far been reported as infected. On Feb 26 2004, sudden death of pigeons observed in Kamakhya Hindu temple in Guwahati, state of Assam (?)
• a general alert has been sounded with the death toll of migratory birds in the Okhla Bird Sanctuary on the banks of the Yamuna, registering yet another casualty on Sun Feb 5 2006, taking the total number of dead birds up to 48. Birds of 8 species comprising 40 shovellers, 2 common teals, a lesser black-backed gull, a brown-headed gull, a little egret, a medium cormorant, a little cormorant, and coot were recovered from the area. Some of the recovered bodies were already putrefied and some were fresh, indicating that death would have occurred at least 2 days before. While the death of the migratory birds in Okhla Bird Sancutary has raised concern about the plight of these annual winged visitors to India, death due to bird flu has been ruled out after a post-mortem. Indications are that the deaths could well have been caused by high levels of toxins in the Yamuna. The post-mortem findings revealed rigor mortis, blotches of haemorrhagic spots on the heart and kidneys and congestion in the lungs. Interestingly, in the gizzard of one of the dissected birds, 3 fish were found undigested. This indicates that the birds had fed recently before dying. 3 dead shovellers were handed over to the Forest Department to be sent to the Indian Veterinary Research Institute (IVRI), Bareilly, and High Security Disease Investigation Laboratory, Bhopal, for confirmatory tests for toxicity and bird flu. One dead bird has been sent to Bhopal and 2 to Bareilly.  The rest of the birds and fish were incinerated on the site in the presence of the Forest Department officials
• a survey carried out on some 1,296 birds showed that H₉ has been detected in Gujarat, with as many as 37 cases testing positive in an extensive survey carried out in zoos, bird sanctuaries, wetlands and poultry farms across the state^ref.
• Maharashtra state^ref : about 50,000 birds died since 27 Jan 2006 at 52 farms in Navapur^{ref1, ref2, ref3}, Nandurbar district, located just 30 km across the inter-state border with Gujarat in Surat district, 400 km (250 miles) north of the Maharashtra state capital, Mumbai (Bombay). On 14 Feb 2006, the outbreak in Maharashtra was reported as a diagnosed case of Newcastle disease; fortunately, samples were forwarded to the government laboratory in central Bhopal town, which confirmed H₅N₁ in 3 out of 8 birds on Feb 18, 2006^{ref1, ref2, ref3}. The samples will be sent to Australia for further verification^ref. Maharashtra state (population over 100 million, area 118,530 sq mi = 306,993 sq km) is situated in West India, on the Arabian Sea^ref. Maharashtra, India's most industrialised state, is the country's third largest producer of eggs. The city of Mumbai [formerly Bombay] is the capital. Around 500,000 birds will be killed in a 1.5-mile radius around the poultry farms^ref. About 300,000 birds have been culled so far^ref. The government will compensate farmers in Maharashtra for the culled chickens by paying 10 rupees for each chick, 30 rupees for a broiler and 40 rupees (90 cents) for a chicken^ref. A 3 km (2-mile) exclusion zone has been established around the infected farm, and another 1 million chickens in farms up to 10 km (6 miles) away will be vaccinated : on Feb 18 authorities began vaccinating 300,000 birds. The Ministry has already dispatched 9,000 doses of Tamiflu and 2,000 sets of personal protective equipment (PPE) to Maharashtra and about 2,000 doses of the drug and 1,000 PPEs have been sent to Gujarat^ref. > 200 veterinary specialists in Maharashtra have been sent to help destroy 700,000 birds at 48 farms (200,000 on Feb 19)^ref and blood samples of 8 people with flu-like symptoms have been sent for testing at a lab in Pune. 4 other people, including 3 children, are also under close observation^ref. There are nearly 1.2 - 1.4 million laying birds in 60-odd poultry sheds around Navapur. These sheds supply eggs to Nashik, Jalgaon, Bhusawal, Surat (Gujarat), Indore (MP), Mumbai and Hyderabad. On Feb 19 a report from a top administrator of India's Surat district in the western Gujarat state and the state's health minister suggested a 28-year-old male poultry farm owner from Nandurbar had fell sick and was admitted to hospital on Feb 8 and died with suspected bird flu in Surat on Feb 18, but the health ministry statement did not confirm this^ref. The government said the man had no history of handling poultry and his death was on account of ``acute respiratory distress'' due to a bacterial infection^ref. About 95 people are being tested for possible human infection as a precaution : 51 clinical samples from people who had been in contact with poultry or had symptoms of upper respiratory infection had been sent to the National Institute of Virology in Maharashtra's Pune city and 44 samples to the National Institute of Communicable Diseases in Delhi^ref. 12 patients with fever and respiratory illness in Navapur sub-district have been hospitalized for observation as a precautionary measure : 2 patients with mild URTI and normal chest X-rays were positive at preliminary tests, were isolated and treated with oseltamivir^ref. 11 of the 12 had tested negative but the 12th was undergoing further tests^ref. About 500 people have walked into makeshift medical camps in Navapur (town) to get checked for cough and cold since Feb 21 : authorities had completed a door-to-door search in Navapur where 30,000 people had been examined. As of 22 Feb 2006, 208 892 birds have been culled in Maharashtra^ref. 12 people quarantined at the Navapur sub-divisional hospital in Maharashtra were hospitalised after they displayed flu-like symptoms : the patients have been isolated and treated with oseltamivir. Clinically, they looked all right and none of them have shown any signs of ‘acute distress’ yet^ref. On Tue Mar 14, 2006, samples of dead birds sent last month to a laboratory in Bhopal from 4 tehsils of Raver, Darangaon, Yaval and Chopada (spread over 1,100 square km (425 square miles)) in the Jalgaon district of Maharashtra (200 km (125 miles) from Navapur) tested positive for H₅N₁^{ref1, ref2} : a total of 45,184 birds have been culled here. With the culling of 91, 000 birds in the avian influenza affected talukas over four days, the culling operation in Jalgaon district of Maharashtra was declared "practically over" on 19 Mar^ref. The deaths of 130 birds out of 30,000 purchased from Mumbai by a trader for selling during Holi in Maval taluka of Pune district on March 14, which triggered panic in the region, was not due to bird flu, but to shocks during travel : a 5% mortality rate is normal in transportation of broilers as they are weak in comparison to backyard poultry and cannot withstand the shock^ref.
• a 11-year-old boy with high fever (but no respiratory symptoms^ref) and a history of exposure to dead birds was given oseltamivir on Sat 18 Mar : the boy's fever, which developed on Fri 17 Mar, did not come down with paracetamol and his temperature shot up to 103°C on Sat night^ref
• a doctor (Dr DA Wankhede) who suffered from diabetes with fever and respiratory problems walked into a local hospital and asked to be put under observation. The doctor is not from the affected region and neither was he exposed to dead birds, but we didn't want to take a chance. The doctor complained of fever after an egg broke in his hands^ref
• a 40-year-old woman (Sarlo Subhash More / Mrs Sarla Subhash Moray^ref), a local poultry owner from Takiri Khurd / Takri Khu-rd village was hospitalised on Sun 19 Mar and kept in isolation after health officials carrying out door-to-door surveillance found her with fever and respiratory problems. Investigations revealed that she had used bare hands to bury a large number of chickens who died 8 days ago. She was treated with oseltamivir^ref. She had recently had a lung operation too^ref
• a 5-year-old girl (Tina Deepak Nanavede) from Kochur village was also diagnosed with classic symptoms. Her grandparents told health officials that 6 chickens had died in their house a week ago and Tina had buried them. She was treated with oseltamivir^ref
All 4 tested negative on Mar 21^ref.
Health officials were monitoring 65,000 people spread over 17 villages. Of them, some 150 people had fever, but authorities said the figure was normal^ref. On Tue 28 Mar 2006, the Center told state and Jalgaon district officials that the virus had been detected in 6 new pockets of Jalgaon district. The new areas Erandol, Uttran, Bhadgaon, Parola, Varad and Paladhi are located close to the 4 villages of Jalgaon district where the bird flu virus was earlier detected. For the state government, the news was not unexpected, as it had made all arrangements for a culling operation about 10 days back over such fears.
On Apr 5, 2006, H₅ was confirmed in 14 new villages in the Jalgaon district of Maharashtra, near the site of 2 earlier outbreaks^ref. Of the 3,509 samples from Madhya Pradesh tested at the Animal Disease Laboratory, only one from Ichhapur village in Burhanpur district has tested positive. On Apr 8, nearly 1,000 birds in 5 villages - Biroda, Bholawa, Garhtal, Pipalphata and Mukhawara - where the birds are being culled are within a radius of 10 km from Pipari village in Maharashtra's Jalgaon district where some poultry samples had tested positive^ref.
• a 30-years old poultry farmer in India's bird-flu hit western region approached authorities on Apr 7 and told them some 600 chicken on his farm had died last week : he was hospitalised on Sat Apr 8 with flu-like symptoms at a government hospital in Ahmedabad^ref
• an Akola-based veterinary surgeon who had supervised culling operations in the affected area of Nandurbar and Jalgaon in Maharashtra fell ill with fever and died : his death was not due to avian influenza infection but rather to jaundice^{ref1, ref2}
• Gujarat state : government planned to go in for immediate vaccination of birds in the border town of Ucchal of Surat district, with the help of a Central team^ref. 3 patients were hospitalized for observation in the Vaira sub-district^ref. As of 22 Feb 2006, 73,157 birds have been culled in Uchchhal Taluka, Surat District. 6 chicken samples taken from 2 different poultry farms on February 13 tested positive for bird flu on Feb 25, including some chickens from the National Poultry Farm in Utchal taluka (Uchchhal Taluka). It was confirmed by the Union government on 2 samples out of 13 sent from the region^ref
• Uttar Pradesh state : poultry deaths were reported Sun Feb 19 from a farm in Bakepur, Etawah district (at least 1,400 chickens died in last 3 days), 230 km southwest of the state capital Lucknow^ref, but on Feb 20 the Joint Secretary, Animal Husbandry Department, Upma Choudhary, told these deaths were due to unhygienic conditions and not due to H₅N₁ virus^ref. > 60% of the state's 2.5 million poultry workers have lost their jobs^ref
• Madhya Pradesh state^ref: avian flu was detected in poultry samples of Ichhapur town in the Burhanpur district on Mar 28, 2006. In intensifying steps to curtail bird flu, over 6,600 chickens were culled in 23 villages. The culled birds were disposed of in 18-10 feet deep pits dug across 5 quarantined zones within 10 km radius of Ichhapur. The government has increased the compensation money to poultry farmers to Rs 60 for every broiler chicken, Rs 40 for layer and Rs 20 for each chick. The administration had recorded 716 birds in 6 villages falling under the alert zone (3 km radius of site of infection) and 5,921 chickens in 17 villages of the surveillance zone (10 km radius of Ichhapur). Around 112 veterinary department staff, including 23 rapid response teams comprising cullers, doctors and handlers, were engaged in the entire operations and were equipped with adequate preventive gear : the staff was administered oseltamivir to prevent spread of infection among them. The teams will cull, clean and mop, following which a drive to disinfect the area and 2,300 houses will be carried out for around 8 days : per Union Health Ministry instructions, the staff involved in the operation will be kept under observation in Ichhapur for 7 days. Vaccinations will not be carried out in the area as birds in both alert and surveillance zones were culled^ref
• Karnataka state^ref :
• Telsang village^ref, located in the Belgaum District and around 30 km east of Athani : 25 people suffering from fever were reported to have symptoms of bird flu and were rushed to the Primary Health Centre on Thur 20 Apr 2006. 3 more cases of suspected bird flu were reported on Apr 24, 2006^ref
A study of the gene sequences (HA1 and HA2) of the 2 H₅N₁ strains (divergent by 3.5%) isolated from the Navapur and Jalgaon outbreaks, concluded that the viruses originated independentely from Qinghai (central China) and Jiangxi (south China), respectively. Jalgaon was the first to be hit and not Navapur -- as widely believed. Though the outbreak at Jalgaon was reported 12 days after Navapur (18 Feb 2006), its virus had evolved earlier. Since the Jalgaon outbreak was in backyard poultry (involving scattered deaths), it was reported later than the Navapur outbreak in which a large number of birds in organised poultry farms died. That was also the reason why it took more time in Jalgaon to control the disease, as it had spread far and wide. Probably the Navapur virus was responsible for the outbreak in Uchhal in Gujarat, and the Jalgaon virus for the Burhanpur outbreak in Madhya Pradesh^ref.
The government has offered farmers compensation of 90 cents per bird, a price farmers say is inadequate. Some 200,000 chickens and domestic birds have been culled in India since 19 to 25 Feb 2006. Hyderabad-based Hetero Drugs, which has been granted a licence for production of oseltamivir, had already made available 5 lakh capsules and would deliver an additional 2 lakh capsules. Mumbai-based Cipla said it would start marketing its generic version of Tamiflu in a week^ref. The World Health Organization has supplied about 200 bottles of Tamiflu in syrup form^ref. Of the 2,100 species of birds found in India at any given time, 350 are migratory. Every year, millions of migratory birds visit thousands of lakes and water bodies in the country. Studies have proved that migratory birds are found in each of the 593 districts in the country. A small district like Bidar attracts 45 species of migratory birds. If migratory birds had brought the disease, each district should have had the infection by now, not just Nandurbar in Maharashtra. Secondly, migratory birds come in September and leave by mid March. If these birds have been carrying the H₅N₁ virus all along, why did they not infect the local birds in September itself^ref. Maharashtra is likely to witness several such outbreaks in the coming weeks because thousands of birds that were infected during the first outbreak in Nandurbar had been illegally shifted to other places in the state instead of being culled, the official said on condition of anonymity. The shifting took place with the patronage of some politicians : such shifting will have surely created fresh hot spots of infection in other places in the state that can flare up anytime. According to the official, while 9 lakh birds were officially claimed to have been culled, the cullers could actually account for only 2.9 lakh birds. It is obvious that nearly 6 lakh birds, many of them possibly infected, had been taken away to other places^ref. In India, 7 poultry farmers committed suicide because the H₅N₁ virus destroyed their livelihood, according to an Agence France Presse (AFP) report that cited information from a farmers' organization. The H₅N₁ infections and subsequent culling that have swept India have cost the industry USD 1.8 billion in 6 weeks, the National Egg Coordination Committee said on 12 Apr 2006. The 7 suicides are not an unheard-of response to the stresses of farming in India. The AFP story noted that nearly 9000 people in 4 Indian states are
thought to have killed themselves in connection with rising costs, debt, and repeated crop failures in the past 5 years.
5 new outbreaks involving large numbers of birds are reported. There were 628,363 birds involved with farms ranging from approximately 11,000 to 251,
000. 4 of the outbreaks were at Jalgaon district, Maharashtra state; the other outbreak was in Burhanpur district, Madhya Pradesh state. The last
case was reported on 18 Apr 2006^ref.
• Myanmar (ruled by the military junta since 1962)^ref : continued to remain free of bird flu. The country has little potential to be affected, partly because chickens were kept in a condition not as crowded as in other countries. Since the outbreak of bird-flu was reported in neighboring countries in January 2004, Myanmar has checked about 8.5 million chickens at nearly 8000 poultry farms across the country as part of its measures to prevent the possible outbreak of bird-flu. There are 63 million chickens in Myanmar, of which 50 million are bred outdoor in rural areas. In the second week of Mar 2005  thousands of chickens died suddenly at a farm at 6-mile Hill near Moulmein University, Mon State in southern Burma. At the same time, some of the pigeons in Rangoon look as if they are suffering from a kind of illness. Following the initial reports of HPAI in Eastern Asia, in Dec 2003, the OIE tried to obtain 1st-hand information on the true situation in all regional countries. Subsequently, 8 countries -- including Myanmar -- reported the absence of disease. The Director General of the Livestock Breeding and Veterinary Department (LBVD) in the Ministry of Livestock and Fisheries, Government of the Union of Myanmar, sent on 16 Feb 2004 an official report to the OIE about the absence of HPAI infection in his country. The report included the following description of the relevant steps taken: "Surveillance and inspection teams have been formed at state/division, district and township levels respectively involving local authority, medical staff from the Health department, and vets from the our department, LBVD. They are to inspect every poultry farm at their designated areas and inform up to HQs through local vets when they find normal or suspected cases. Most of the cases found in Myanmar are Newcastle disease (NCD), Marek's disease and chronic respiratory disease (CRD = Mycoplasma). Up to now, we have not encountered suspected case of AI that meet the criteria of 100% mortality or above 40% within 3 days. We performed diagnosis based on clinical signs, PM lesions, virus isolation, HA/HI tests and ELISA techniques. No suspected human RDS case related to AI were reported from the medical side as well". In January 2005, the following citation was published in a newswire : "The World Health Organization has said the avian influenza virus might already have infected people in countries neighboring Viet Nam such as Cambodia, Laos and Myanmar, but these countries lack the infrastructure or capacity to conduct necessary surveillance". Renewed surveillance efforts are required to confirm or -- hopefully -- refute the recent rumors from Myanmar. The other 7 countries which reported the absence of HPAI were (parentheses indicate dates of notifications of "cleanliness"): Bangladesh (2 Feb 2004);  Mongolia (12 Feb 2004); Philippines (12 Feb 2004); Singapore (12 Feb 2004); Nepal (16 Feb 2004); India (04 Mar 2004); Sri Lanka (29 Jul 2004). The Norway-based opposition Democratic Voice of Burma reported at the weekend that thousands of chickens had suddenly died in Mon State and local residents feared it could be bird flu. On 16 Feb 2004, the Livestock Breeding and Veterinary Department (LBVD) in the Ministry of Livestock and Fisheries, Government of the Union of Myanmar, sent to the OIE an official report about the absence of HPAI infection^ref. On 8 Mar 2006 112 chickens out of a flock of 780 died on a farm in Aung Myae Thar Zan township near Mandalay, about 430 miles (700 km) north of the capital Yangon [formerly known as Rangoon]. Officials destroyed the remaining 668 chickens and sent samples for testing at the Central Veterinary Diagnostic Laboratory, Yangon and the Regional Veterinary Diagnostic Laboratory, in Mandalay : on Mar 12, H₅N₁ was confirmed by the government laboratories in Mandalay and Yangon at a farm and 4-5 farms were quarantined; samples had also been sent to laboratories in Australia and Thailand^{ref1, ref2, ref3} and on Mar 16 tests confirmed the diagnosis^ref. However, Myanmar apparently made no public announcement to its people about the outbreak. Only a handful of residents in Mandalay, contacted by telephone, had heard the news on shortwave radio stations broadcasting from overseas^ref. In Yangon, state-controlled media ended a news blackout on Thu 16 Mar 2006 and published details of the Mandalay outbreak and the measures taken to contain it. The New Light of Myanmar reported that a total of 5628 chickens and 4482 quail died in poultry farms in 3 townships (Shwebo, Kanbalu and Khin U) in northwestern Sagaing division, and 4 townships (Pyigyidagun, Chanmyathazi, Chanayethazan and Amarapura) in northern Mandalay division^ref, as of 16 Mar 2006 : authorities slaughtered a total of 13,970 chickens and 77,018 quail and quail eggs in these townships^ref. Officials temporarily closed poultry markets and banned bird movements in the 2 townships. Officials investigated suspicious poultry deaths in 2 other townships in Sagaing Division but found no bird flu^ref. Though neighboring countries (Thailand, Laos, China) have been affected by H₅N₁ since the earliest stages of the H₅N₁ panzootic, Myanmar has persistently claimed freedom from the disease. On 16 Mar 2006, 7 new outbreaks were reported in layers chickens and quail in Mandalay and one in Sagoing. In Mandalay, there were between 50 and 400 cases reported in the outbreaks and 155 cases in Sagoing. All the cases resulted in deaths in Mandalay, while only 5 deaths were reported in Sagoing division, Shewbo district^ref. On Apr 10, a UN team reported that up to now, there are > 100 outbreaks, mainly in 2 districts, Mandalay and Sagaing. A historic trading hub between India, China and Thailand, Mandalay

lies in the center of the country and Sagaing in the north^ref
• Nepal : at least 90 persons have taken seriously ill as at Thu, 4 Feb 2004 with an unknown disease which has spread in the past few days in central district of Dolakha. The symptoms of the disease are breathing difficulty, fever, giddiness, lethargy, and cough. Those infected range in age from 1.5 to 75 years, and most of them came from Pawati village, more than 100 km northeast of Kathmandu. The symptoms, although scant in presentation, do make it sound like the illness could be chemical in nature. If it were leishmaniasis, Japanese encephalitis, Nipah, SARS, or AI, etc., the numbers of cases would be much lower in the same time frame, and the spread would be much further. The number and ages of people involved are rather suggestive of an aerosolized chemical. The clinical signs/symptoms make one think of BZ. An outbreak of suspected AI in Nepal was reported on 8 Feb 2004^ref : > 200 chickens died of an unknown disease in the previous 10 days in the central district of Bara, causing panic among the local people, who ascribed the deaths to bird flu that are spreading in some East Asian countries. The epidemic broke out in Bramhatole Bairiyam of Kalaiya, over 100 km south of Kathmandu. However,  the district veterinary office chief said that -- as neither the diseased nor dead chickens had been brought to the veterinary office -- it was hard to tell what disease the chickens had succumbed to. The age distribution of the cases in the current outbreak of influenza in the human population, however, would be more consistent with  an outbreak of classical human influenza rather than AI. It was reported on Mon 8 Mar 2004 that 16 people have died of viral influenza within one week in Mugu district. The disease has hit several villages of Ruhga VDC, but most of the casualties have been in Ward No.6. The deaths of large numbers of pigeons at the premises of Manakamana temple in Gorkha district, 175 km west of Kathmandu, on Oct 2005 were not related to bird flu. The reason for the deaths could be change in climate, food and fatigue caused by long journey : some of the pigeons were brought from terai region and India in order to sell during the Durga Puja. Manakamana temple is a famous Hindu pilgrimage site where thousands of devotees visit with the belief that worshipping at the temple would get their wishes fulfilled. Nepal government has already banned illegal import of chickens during the festival seasons of Dussera and Diwali to prevent possible spread of bird flu and established quarantine at the Kathmandu airport. Since 26 Mar 2006, hundreds of wild and farmed birds including crows and doves died at Dabara village of Buddhi VDC in Kapilvastu district (other names: Piprahwa, Taulia, Taulihaw, situated on Nepal's (southern) border with India, Lat 27.5333, Long 83.0500^ref) in western Nepal : it was not in a position to confirm or rule out the possibility of avian influenza. Hundreds of wild and domesticated birds had died in the far-western district of Kailali and in the eastern district of Saptari a few days back^ref
• Malaysia^{ref1, ref2} was still free of bird flu after a suspected case in a bird shop owner in Kelantan state near the Thai border proved to be a false alarm. An outbreak, believed to have been spread by a fighting cock brought in from Thailand, in 2 chickens at a backyard operation consisting of 103 chickens and ducks and 62 pet birds of mixed ages reared in free-range began Aug 7 2004, was discovered during routine checks on 17 Aug and was confirmed on Aug 19 in Kampung Baru Pasir Pekan village, Tumpat district, Kota Bharu, capital of the northern state of Kelantan (N 06 min 07.003 - E 102 min 13.448), some 10 km to the border with southern Thailand and 100 km south of Narathiwat, Thailand, where bird flu cases were reported in February and July. Narathiwat and Baru Pasir Pekan Village are connected by both river and road. H₅ type AI has been detected on 19 Sep in 3 chickens in Jalan Bayam Guchil at Teluk Baru village, just 6 km from Pasir Pekan Village. It has since spread to 9 villages in 4 districts of the state -- Tumpat, Kota Baharu, Pasir Mas and Bachok. Since the virus was detected in the state, a total of 5119 chickens, ducks, and birds had been culled in Kelantan. The last case of the virus was detected on 10 Oct, but new birds from Kelantan tested positive on Nov 23. There has been no outbreak reported since November 2004^ref. During the last few outbreaks, there was an unusual disease pattern, with low or no detected mortality (mortality 2 to 40% in infected village poultry). The most recent isolates of virus (in November 2004) were from clinically normal birds in villages with no apparent increase in chicken mortality. Since Nov 3 2005 11 wild pigeons died in Taman Mutiara, Sungai Petani, in Kedah state and in Perak state, but tested negative on 9 Nov 2005.
• Selangor state (central) : on Feb 20, 2006, tests at Veterinary Laboratory in Petaling Jaya and the Veterinary Research Institute in Ipoh confirmed that 40 chickens died from H₅N₁ at 4 villages within a 1.5-km radius  (kampong's or kampung's : Pasir Wardieburn^ref (Setapak city, Wilayah Persekutuan state; since Feb 6, 50 ayam kampung (free-range chicken) deaths and 100 culled; hold by the 66-years old retired soldier Sharip Ibrahim and by the 69-years old Hashim^ref), Taman Danau Kota, Pekan Danau Kota and Belakang JPJ) along Jalan Genting-Klang in the central Malaysian Gombak suburb, just outside Kuala Lumpur^{ref1, ref2}. Officials and staff of the Veterinary Services Department, Kuala Lumpur City Hall health department and Health Ministry culled 495 chickens, ducks and birds in a 5-hour operation that ended at 4 a.m. 22 Feb 2006^ref. The authorities screened > 2,000 people from 505 homes, but only 7 people (2 adults and 5 children) with respiratory tract infections staying within 300 m (1000 feet) of the outbreak site and exposed to sick chickens were admitted to hospital : on Feb 22 bird flu tests showed negative for 5 (2 adults and 3 children aged between 4 and 44) of them : authorities are still waiting for test results on the remaining 2, both children^ref. On Feb 24 all 10 people quarantined tested negative^ref. Surveillance tasks would be extended to a 10-km (6-mile) zone stretching into the heart of Kuala Lumpur in an operation that will run until 3 Mar 2006. Since Mon Feb 20, 1970 chickens, 62 ducks and 72 other birds have been killed and 516 eggs destroyed. No new cases of H₅N₁ have emerged since 19 Feb 2006, with clinical tests on swab samples from 329 birds so far turning out to be negative. Chicken sales plunged 30% following a new outbreak of the deadly H₅N₁ virus^ref.
• Perak state (southern) :
• on 9 Mar 2006, as a routine surveillance, authorities sent 5 fecal samples of birds in Ecopark of Bukit Merah Laketown Resort, near Taiping, in the top NW corner of the country^{ref1, ref2}, renowned for migratory birds, to the Veterinary Research Institute for testing : on Mar 15, 2 cases of H₅N₁ avian flu strain were detected. There are 249 birds from 30 species living in an enclosed area at the Ecopark. The 0.404 ha bird park at the 1.2 ha resort would be closed indefinitely^ref. The 22 staff members at the resort's Ecopark were asked to undergo medical check ups^ref.
• Kampung Changkat Tualang in Kota Baru near Gopeng, some 100 km from the Ecopark, was near a bird sanctuary and near to a chicken and duck farm: 38,749 birds located within a 1 km radius of the affected areas would be culled^ref. 500 kampung (free range) chickens at Kampung Changkat Tualang and chickens and ducks at a poultry farm nearby would also be culled. The farm has 8000 day-old chicks, 20 000 day-old ducks and 10 000 ducks that were 50 days old. At the Ecopark, a total of 249 birds from 30 different species will be culled^ref. On 16 Mar 2006, a 34-year-old poultry farmer from Kampung Changkat Tualang whose backyard free-range chickens died from H₅N₁ virus infection since Mar 12 (confirmed on Mar 15) was believed to have suffered from symptoms related to avian influenza (anorexia, cough and pruritus). About 80 villagers living in the area also reared poultry for a living^ref.
• Kampung Changkat Legong near Gopeng : 2 free-range chickens in the village were found infected on Mar 22, 2006 following random testing within the 10-km radius of Kampung Changkat Tualang. 1500 free-range chickens were culled^{ref1, ref2}
• Titi Gantung Agriculture Training Institute in Bota : on Mar 22, 2006 found in 6 samples of broiler chicken^{ref1, ref2}
• Taman Lapangan Perdana in Ipoh : outbreak discovered on Mon Mar 21, 2006 in 1 out of 2 dead burung gembala kerbau (cattle egret) discovered by residents. Since their origin could not be determined, culling didn't occur^{ref1, ref2}
• in Butterworth, the health authorities are monitoring areas (Kepala Batas, Bumbung Lima, Tasek Gelugor, Pongsu Seribu, Teluk Air Tawar, Penaga, Bagan Ajam, and Sungai Dua) within a 10-km radius of Permatang Bogak in northern Seberang Perai^ref
On 18 Mar 2006, officers of Penang^ref Bird Park^ref in Seberang Jaya slaughtered 20 chickens, 5 ducks and 7 geese in the premises although they were free from H₅N₁ : while inbred poultry is considered to have weaker immune systems, the rest of the park's attractions were wild birds and unlikely to be at risk because they have a natural immunity against the H₅N₁ avian flu strain^ref. Penang Bird Park is the 1st and largest bird park of its kind in Malaysia. Established in 1988, the 5-acre park on the mainland portion of Penang State has a collection of >2500 birds of > 300 species from all over the world, of which > 150 species are of Malaysian species. > 3000 birds in this park are carefully and scientifically housed in > 150 cages for breeding and conservation purposes. The Geodesic Domes and 2 giant sized Walk-in-Aviaries keep hundreds of tamed birds, which offer a priceless memory and exciting moment for visitors upon hand-feeding them. Exotic birds ranging from tiny sunbirds to huge, gigantic 8-foot tall Ostriches frolic in an environment that imitates their natural habitat. Penang Bird Park is particularly proud of its hornbill, sunbird, and pheasant collection. It is an avian zoological garden^ref. > 900 people of Permatang Bogak were checked by the Health Department since March 20 following the detection of the H₅N₁ bird flu virus in the area to prevent its spread to humans : officials from the department had checked more than 250 houses in Permatang Bogak and also briefed the residents on the dangers of the disease. 3 of the residents, who were down with temperature > 38°C and showed flu symptoms, had been warded at the hospital. However, the results of the tests on 2 of the patients, who were admitted to the Penang Hospital and Kepala Batas Hospital respectively, showed up negative for H₅N₁ and they were discharged from the hospital, while the third patient, a girl who is 2 years and 9 months old, who was admitted to the Penang Hospital Thursday was still under treatment while waiting for the outcome of the test from the Institute of Medical Research in Kuala Lumpur^ref.
• Penang state (northern) : on Mar 20 an outbreak was reported in birds in Permatang Bagak village^ref. After tests confirmed that at least 6 chickens died of H₅N₁on Mar 20, officials will slaughter > 200 birds^ref
Wilayah Persekutuan, Perak, and Penang States in Peninsular Malaysia are no longer considered HPAI-infected zones. Malaysia regained its highly pathogenic avian influenza-free country status on June 22, 2006^ref.
• Mongolia : on Mar 11 2004, 17 birds including 5 crows have been found dead around Erdenetsagaan soum county of Suhbaatar aymag province, eastern Mongolia (?). Since Aug 2, 2 outbreaks occurred in migratory birds (wild ducks, geese and swans) in the northern part of the country^ref :
• 80 birds were found dead at Erhel lake, Alag-Ederne county, Huvsgel [Hovsgol] province in northern Mongolia^ref : laboratory diagnosis was made on 7 Aug 2005. Causal agent: avian influenza virus type A. Subtype identification is ongoing. The H₅N₁ outbreak in wild birds appears to have extended its range to include Western Mongolia. Previous reports had just located an H₅N₁ virus in both Russia and Kazakhstan, some 1000 km further west. It would be very important to determine whether all 3 outbreaks have a similar genetic composition to the causative virus^ref. At the lake the Wildlife Conservation Society (WCS)/Mongolian Government team counted over 6500 apparently healthy birds of 55 different species. Over the course of the survey, the team collected samples from 774 individual birds from the 10 sites. The majority of samples were faecal samples but also included tissues from 4 birds found dead at the site. Samples came from the following species: bar-headed goose (Anser indicus), herring gull (Larus argentatus), black-headed gull (Larus ridibundus), Eurasian widgeon (Anas penelope), ruddy shelduck (Tadorna ferruginea), and whooper swans (Cygnus cygnus). Supported by FAO, the team sent the samples (774 in total) to the USDA's Poultry Research Laboratory in Athens, Georgia, for further testing to determine whether this virus is the H₅N₁ strain that has killed over 50 people in Southeast Asia and > 5000 wild birds in western China. On Aug 19, a report from the Wildlife Conservation Society, notified the identification of H₅N₁ using RT-PCR in 1 dead whooper swan (Cygnus cygnus)  tested in USDA's Poultry Research Laboratory in Athens, Georgia. The WCS posting also provided other important results from the same lab: 30 live whooper swans living at the same site and also a nearby lake were negative for the virus. Samples collected from other live birds at the 2 sites, including 60 ruddy shelducks, 24 bar-headed geese, and 25 black-headed gulls, were found to be negative for the virus^ref. Samples were sent by the Mongolian authorities on 15 Aug 2005 to the OIE Reference laboratory in the Hokkaido University, Japan. Final results on 4 of them (samples No 1,3,4 and 6), 1 bar-headed goose (Anser indicus) and 3 whooper swans (Cygnus cygnus), were received on 24 Aug 2005 : the virus was identified as H₅N₁; the laboratory is expected to further study the isolate, particularly comparing it with previous isolates from the region^ref. It has been argued that these (as well as previous observations in China's Qinghai Lake wildlife refuge) may indicate that the waterfowl species typically identified in recent outbreaks appear to be victims rather than effective carriers of the disease. Further research is urgently in need. This event reflects an exemplary proactive, transparent attitude of the Mongolian authorities and a commendable cooperative effort of international experts and laboratories. Lake Erhel is just 350 km southwest of Lake Baikal in Siberia, the largest freshwater lake in Eurasia; it will be interesting to note if surveillance in wild birds has been undertaken there as well.
• 9 birds died at Khunt lake, Saikhan county, Bulgan province
• Singapore imports from the USA 9% and from Brazil 50% of total frozen chicken meat. Singapore authorities placed 19 sentinel chickens in the Jurong Bird Park, which has > 9000 birds of 600 species including such endangered ones as the Toco Toucans, Caribbean Flamingos and Dalmatian Pelicans (the world's largest in terms of number of birds and 2nd largest in terms of land area after Germany's Vogelpark Walsrode). Since 2004 the park has started vaccinating all other birds and giving flu jabs to its staff. It has also introduced foot baths and disinfecting floor mats to reduce the risk of spreading the virus. The use of sentinels in zoos or open-air parks for the detection of newly-introduced exotic disease agents, such as avian influenza or Newcastle disease, is an interesting application of a technique which has previously been used mainly in commercial farms. Some examples : in 1995, Mexico -- suffering an H₅N₂ outbreak -- used sentinels, kept in AI vaccinated poultry farms, to monitor the efficacy of the vaccine and to detect new infections.  During the 2003 epizootic of highly pathogenic H₇N₇ avian influenza in the Netherlands, repopulation of the culled affected holdings was allowed only after "sentinel birds" demonstrated that the virus was no longer present in the holding. In Hong Kong, the 1st territory in southeast Asia which detected human infections with H₅N₁ (as early as 1997), all chicken farms are routinely vaccinated with inactivated H₅N₂ vaccine, and each batch of chickens has 60 unvaccinated individually identified sentinels monitored throughout the production life of the batch. Hong Kong also conducts an extensive virus culture and surveillance in bird parks and in captive birds. Singapore's decision to use sentinels is a creative solution to a specific situation when direct or indirect contacts (e.g. droppings) between the avian population of local parks on the one side, and wild or migratory birds on the other side, cannot be prevented. In contrast, commercial poultry are isolated from wild birds by their housing, while indirect contacts can be prevented by adequate biosecurity measures. A feverish 38-year-old Vietnamese woman married to a Singaporean complained of fever and giddiness, went to a clinic near her home on Saturday and was finally transferred to the Singapore's Communicable Disease Center (CDC) as a precautionary measure because she had traveled to Vietnam recently : she was been cleared of avian flu on Dec 18
• Pakistan^{ref1, ref2} : during November 2004, outbreaks of H₇ avian influenza were reported in unvaccinated chickens in Haripur and Abbottabad, North Western Frontier Province; H₇N₃ and H₉N₂ were isolated from chickens in Karachi. Since Feb 23, 2006, thousands of chickens reportedly died in various border areas of Pakistani Kashmir, including Dhadiyal and Mirpur^ref. 4 outbreaks confirmed :
• since 23 Feb 2006, outbreaks occurred at a small breeder farm in Abtabad / Abbotabad / Abbottabad, 125 km (80 miles) north of the capital (16 000 susceptible / 1045 cases / 875 deaths / 15 125 destroyed), and at a commercial egg farm in Charsadha / Charsada, 120 km (75 miles) northwest of Islamabad (10 450 susceptible / 2420 cases / 2000 deaths / 8450 destroyed), in North West Frontier Province (NWFP)^ref. On 26 Feb 2006 several dead birds tested positive for LPAI H₅ and on 27 Feb Pakistan ordered the culling of 23,000 chickens and quarantined some farms^ref : the samples tested positive at VLA on Mar 21^{ref1, ref2}. The 1st suspected avian influenza death in Pakistan occurred at the Doctor's Hospital, Johar Town : the victim, his mother, and younger brother also allegedly died in a span of 15 days. The victim (a 27 year old man) had been attending his younger brother : he was brought from Gujranwala in serious condition on Feb 25, 2006 and was admitted to the Doctor's Hospital. He was put in a private room, but transferred to the Medical Intensive Care Unit (MICU) by Dr Kamran Cheema and Dr Sobia Qazi. He was kept in a separate room in the MICU and all doctors and nurses concerned were handling the patient with gloves. Nobody was allowed to meet the patient. There were also rumours that another member of his family was being treated at Doctor's Hospital. The victim's family said Dr Cheema had told them that their relative had died of the same virus his brother had died from. The family took the victim's body back home, but left another family member at the hospital for further treatment^ref. There had been no other cases of bird flu since the outbreak was first reported on Feb 27, 2006, at farms in the North West Frontier Province and there were no cases of humans being infected^ref. Tests on birds from central Punjab and southern Sindh provinces have proved negative and a nationwide survey was being conducted as a precaution^ref. No bird flu was found in 18,842 poultry samples, both commercial and domestic, collected from April 2004 to Mar 2006 from Karachi, Hyderabad, Mirpurkhas, Thatta, Dadu, Nawabshah, Sukkur, Larkana, Shikarpur and Khairpur. Since November 2005 till date, 40 samples of migratory birds were also analysed but no bird flu was discovered : samples were taken every week from Karachi, Thatta, Hyderabad, Dadu and Mirpurkhas under a comprehensive system which were being regularly analysed in Karachi^ref. Over dozens of crows are dead in Dahangaw village, while > 100 chickens died in Asatian village in Bamyan district [Punjab, Central Afghanistan, Latitude 34.8167, Longitude 67.8167^ref]. A cat also died after eating a dead bird that had shown the symptoms of bird flu. Scores of wild migratory birds had been found dead in the Ghosak area : the white birds had arrived during Nawroz festival days. People in the area were concerned about the possible outbreak of bird flu. Authorities don't have facilities for diagnosing bird flu. About 2 weeks earlier, many dead birds had been found in a pool in the outskirts of Bamyan city; people since then had stopped using water from that pool^ref. According to Pakistan's follow-up report No. 1, sent to the OIE on 4 Apr 2006, no further outbreaks had occurred since February 2006, while -- as a precautionary measure -- "the private sector has been allowed to import 5 million doses of avian influenza vaccine to deal with any eventual emergency^ref. Data on the vaccine used in Pakistan (probably H₅N₂) will be appreciated
• on Apr 16, 2006 bird flu was detected on a chicken farm in Sihala, 15 miles east of Islamabadon. Health officials have reportedly destroyed 3,600 chickens at the farm and are testing poultry at nearby farms^{ref1, ref2}. Another poultry farm number 45 in the said locality has also been closed down due to fear of presence of the deadly virus : up to 3000 chickens were culled, the poultry farm has been completely sealed and people are barred not to come close to the area^ref
• on Apr 20, 2006, officials had quarantined a farm and several workers in Tarlai on the outskirts of the capital Islamabad : 15,000 birds were culled^ref.
• on Apr 23 13 farms tested positive in Tarlai and Alipur Farash areas, and authorities culled over 40 000 birds^ref
• on Apr 30, a team of experts culled 800 birds at a poultry farm at village Sarwala near Attock where avian flu virus was found. Attock City^ref, appx 100km north-west of Islamabad and Rawalpindi, is the administrative headquarters of Attock district in Punjab province of Pakistan^ref
• on Thu 4 May 2006 authorities culled over 6000 chicks and chicken birds following outbreak H₅N₁ at 2 poultry farms in the Teratt area of Murree, about 35 km north east of Islamabad, and Sialkot, 400 km south east of Islamabad^ref
Human cases :
• a 22-year-old man, his sister, 8, and another woman, 44, were brought to the Pakistan Institute of Medical Sciences (PIMS) on Tue 18 Apr 2006 with apparent symptoms of avian influenza. All 3 are from Sihala village near Islamabad, where the government confirmed the H₅N₁ strain in birds on Sun 17 Apr 2006. The administration of the hospital has, however, very tactfully attempted to camouflage the incident by keeping these patients in one of the medical wards rather than treating them at the isolation ward meant for such cases. The incident took place a day after federal Health Minister Nasir Khan ruled out the possibility of bird-to-human transmission of the virus. It came 2 months after Pakistan 1st confirmed the presence of the H₅N₁ virus in birds and 7 months after the World Health Organization (WHO) warning that the bird flu could hit South and Southeast Asia. The government and its agencies -- health and food ministries -- have so far been telling people not to give up eating cooked chicken and eggs in a desperate attempt to save the Rs 70 billion [USD 1.2 billion] per annum poultry industry. After we received a call from a source reporting the incident, PIMS officials denied any such case when contacted for confirmation. Health Minister Nasir Khan and PIMS Executive Director Dr Fazl-e-Hadi did not bother to receive telephone calls from these correspondents. PIMS Spokesperson Dr Wasim Khwaja, when telephoned, neither confirmed nor denied the case, with a view that it was a sensitive matter and he could not comment on it. He referred these correspondents to his deputy, Dr Ghulam Akbar, who at that time was on duty at the hospital. Before that, when the isolation ward was visited, the doctor on duty, Dr Abdullah, denied he had received any patient from the Sihala area with avian influenza symptoms. Dr Abdullah said that if any patient with bird flu came to the hospital, he or she would be treated at this ward and that at the moment, there was no such case^ref.
• Philippines : on 7 Jul 2005 in a routine testing done on samples collected from a small farm (280 animals : 230 native ducks, 20 native chickens, and 30 2-day-old chicks) in Calumpit city, Bulacan province, a low pathogenic H₅ AI virus was detected in ducks only using hemagglutination inhibition and PCR. All ducks in the farm are apparently healthy with no mortalities^ref. Water poisoned by an "unlabeled antibiotic" bought from the local market -- not bird flu -- caused the sudden death of 50 free-range chickens in a northern village outside the town of Calumpit on Fri 7 Oct 2005. On Mar 20, 2006, members of the Task Force Bird Flu in the Autonomous Region in Muslim Mindanao are closely monitoring Barangay Kauran village, Ampatuan, Maguindanao following the successive deaths of poultry animals in the area^ref.
• Russia^ref : there are about 233 million head of poultry in commercial enterprises in Russia. Influenza A viruses of different subtypes were isolated from fecal samples of ducks in their nesting areas in Siberia in summer from 1996 to 1998. Phylogenetic analysis of the NP genes of the isolates in Siberia and those in Hokkaido, Japan on their flyway of migration from Siberia to the south in autumn revealed that they belong to the Eurasian lineage of avian influenza viruses. It is noted that the genes of the isolates in Siberia are closely related to those of H₅N₁ influenza virus strains isolated from chickens and humans in Hong Kong in 1997 as well as to those of isolates from domestic birds in southern China. The results indicate that influenza viruses perpetuated in ducks nesting in Siberia should have contributed genes in the emergence of the H₅N₁ virus in Hong Kong. Vaccine prepared from avirulent A/duck/Hokkaido/4/96 (H₅N₃) influenza virus was potent enough to protect mice from challenge with lethal dose of the pathogenic H₅N₁ virus. Intensive surveillance study of aquatic birds especially in Siberia is, therefore, stressed to provide information on the future pandemic influenza virus strains and for vaccine preparation^ref. In a joint AI project in wild birds between laboratories at the "Vector" State Virology and Biotechnology Institute (Novosibirsk, Russia), the Ivanovski Institute of Virology (Moscow, Russia) and the U.S. Department of Agriculture (Athens, Georgia), several AI viruses including H₅-type influenza viruses have been isolated from migratory birds in Russia over the past 4 years. In 2003, an H₅ LPAI A virus was isolated by the Laboratory for Investigation and Surveillance of Emerging Zoonotic Diseases (Novosibirsk, Russia) from a wild mallard duck on lake Chany in the south of Western Siberia (in the lowland zone of Barabinsko-Kulundinskoj (Novosibirsk area), where annually ducks and geese winter) and sequenced to determine relatedness to other H₅-type AI A viruses in Asian poultry. The A/mallard/Chany/9/03 AI A virus was related to, but was not identical to current AI A (H₅N₁) viruses circulating in domestic poultry in Asia. The A/mallard/Chany/9/03 AI virus has HA sequence similarity in the 90-95% range to the current Asian influenza A (H₅N₁) virus, which is similar to sequences of other Eurasian H₅-type AI viruses, including A/duck/Potsdam/1402-6/86 (H₅N₂) and A/turkey/England/50-92/91 (H₅N₁). These data emphasize the need for continuing surveillance of migratory birds for AI viruses, and studies of such viruses will increase our understanding of the ecology of AI viruses, especially in transfer of such viruses between migratory birds and domestic poultry. However, the A/mallard/Chany/9/03 AI virus is not the same virus as the Asian H₅N₁, and is not evidence of infection and spreading of the current Asian H₅N₁ AI virus by migratory birds outside of the 7 infected Asian countries/regions.
• 7 eastern regions bordering Kazakhstan
• Russia's Siberian Federal District : although H₅N₁ outbreaks in Siberia followed migratory bird routes, they were also close to the Trans-Siberian railway and road corridor and occurred in summer when birds were moulting and non-migratory, suggesting human involvement in virus transport^ref.
• since 15 July 2005 an outbreak occurred in private farms of chickens, turkeys, ducks, and geese in 11 (15?) settlements (with another 25 suspected) in 13 villages in the 4 districts of Kupino / Kupinsky (since Jul 18; 240), Dovolnoye / Dovolinsky (since Jul 22; including 300 in the village of Suzdalka) and Chistoozernoye / Chistoozerny (since Jul 22), and Zdvinsky in Novosibirsk oblast (region) (Novosibirskaya oblast, situated within the more easterly Siberian Federal District), among birds in non-commercial premises of open type : this area is within the zone of Barabinsko-Kulundinskaya lowland, adjacent to a crossroad of bird migratory routes. No human cases have been reported. Significant mortality was detected on 18 July. > 2,000 birds of different species (200 geese, ducks, turkeys, 100 chickens) died.
• In 5 villages, birds have shown clinical signs of the disease, and deaths have been reported; birds have tested positive to antibodies to H₅, and the virus has been isolated.
• In 4 villages, no deaths have been reported, but birds have tested positive for antibodies to H₅, and the virus has been isolated.
• In the remaining 4 villages, no deaths have been reported, nor has the virus been detected in any of the birds. However, birds have tested positive to antibodies to H₅.
Pathological material was sent for laboratory analysis and the results on Sat 23 Jul 2005 Alexander Shestopalov, a virologist with the state scientific centre for virology and biotechnology (Vector), told the Russian news agency Interfax that the virus was a low pathogenic strain called H₅N₂. Russia's formal notification to the OIE on 24 July, however, indicated that they had not yet characterized the virus, and knew only that it was an H₅ type^ref. Considering the low mortality rate (< 3.3% in localities where the infection has resulted in deaths of birds), the virus titres are very high in some samples of pathological material. No signs of the disease have appeared in commercial poultry farms in the region. On 29 July 2005 new tests showed serotype H₅N₁. Despite no evident species specificity, and the pattern of spread within a settlement, HPAI was confirmed on 5 Aug 2005. Infection of domestic birds in all the affected localities, some of which are up to 600 km apart, occurred simultaneously. In all cases, the source of infection was wild waterfowl in lakes frequented by domestic birds. This is proposed as the primary source of the virus. The Novosibirsk region confirmed bird flu in 27 settlements in 8 villages and suspects the infection in another 37. As of Aug 22, local veterinary services have culled 69 658 poultry in the 11 affected settlements. No mass die-off has been registered since Aug 24. In 2 settlements, medical observation has ended. In Oct 2005 16 communities are currently under suspicion.
• Altai territory ("Kray") : > 300 domestic fowl died in 18 villages in 10 regions. As of 19 Aug 2005, bird flu was detected and confirmed by laboratory tests in 17 villages in 10 districts (including Zavyalovsky, Mamontovsky, Romanovsky, Baevsky, Yegorievsky) were affected by the epizootic. In 5 settlements, medical observation has been discontinued and the quarantine has been lifted. Mass die-offs in domestic birds has not been recorded since Aug 24. Laboratory tests are being carried out for another 8 settlements in 8 Altai districts. 13 667 birds were destroyed. A mass die-off of domestic birds has been registered for the 1st time in the village of Khabary in the district of Khabary. On 12 Oct 2005 outbreaks occurred in 2 settlements. On 26 Oct 2005 an outbreak occurred in Pokrovka Village. On 27 Oct an outbreak occurred in Novichiha Settlement. On Oct 31 2005 an outbreak occurred in Grjaznova Village.
• Omsk oblast (region), situated within the more easterly Siberian Federal District: > 450 domestic fowl have died due to apparently non-HPAI : bird flu was confirmed in 15 settlements in 3 (5?) districts (Sargatsky, Marianovsky, Okoneshnikovsky), where 5997 birds have been killed, including 2 populated areas and on 4 lakes among waterfowl. Results of bird flu tests are due in 32 Omsk region settlements. In 13 settlements deaths of domestic birds were recorded; in 2, only deaths of wild birds. Since Aug 24, mass die-offs of birds have not been recorded. Medical observation was ceased in 2 villages.About 142 000 birds are being monitored at a commercial farm. Another 18 settlements in eight districts are expecting test results for a final confirmation. On Oct 27 an outbreak occurred in chickens and ducks in Rozovka Settlement, near the border with Kazakhstan. On Nov 3 an outbreak occurred in Novosanzharovka
• Tomsk oblast (region) : as of 9 pm, 8 Sep 2005, 5460 blood samples arrived at the regional veterinary laboratory for AI testing. 1956 samples came from poultry plants, 73 account for synanthropic birds (pigeons), 2728 were from poultry (chickens, ducks, geese), 694 from wild birds, 9 from the zoo (Seversk). 5441 samples tested negative for AI. Blood serum samples from wild ducks killed on 15 Aug 2005 in Verkhneketsky district were found to contain antibodies to the H₅ virus in the titre 1:32. The blood serum of 2 wild ducks from Orlovka, Teguldetsky district contained antibodies to avian influenza H₅ type in the titre 1:16. The blood serum from a raven that came in 19 Aug 2005 from Teguldet contained antibodies to AI type H₅ in the titre 1:32. Antibodies to AI H₅ were found in titre 1:32 in blood serum taken from a wild duck killed 22 Aug 2005 near the village of Druzhny, Verkhneketsky district. Antibodies to AI H₅ were found in titre 1:32 in blood serum from a wild duck that arrived 28 Aug 2005 from Rodionovka, Kolpashevsky district. Antibodies to AI H₅ were found in titre 1:16 in a blood sample from the island of Timyan, Krivosheinsky district. 11 more samples are being tested. Based on the results received from the Novosibirsk interregional veterinary laboratory genetic material of AI type H₅ was found in 4 samples taken from wild ducks that were delivered 30 Aug 2005 (Kolpashevsky, Verkhneketsky, Krivosheinsky, Tomsky district). No outbreaks or losses of poultry in the Tomsk region have been registered. It will be useful to obtain more information on the H₅ virus strain reportedly detected in Tomsk from wild ducks, as well as about the ducks' clinical status. Was this an H₅N₁? If not, which serotype? If affirmative, has it been compared to other Asian/Russian isolates?
• Altay Republic : a wild (healthy?) duck shot near the village of Verkh-Karaguzh (Upper Karaguzh) is the only case found in the republic. The Altai Republic is situated at the very centre of Asia at the junction of the Siberian taiga, steppes of Kazakhstan, and semi-deserts of Mongolia, bordering Mongolia (SE), China (S), Kazakhstan (S/SW), and Russian Siberia (Kemerovo, Khakassia, and Tuva) on the north. Area 92 600 sq.km (35 800 sq mi); population (2002) 202 947.

The Altai territory ("Krai") and Altai republic are 2 different, though neighbouring, entities. The republic is situated southeast of the krai^ref.
• Urals Federal District (Administrative center: Yekaterinburg)^{ref1, ref2} :
• Tyumen oblast (region) (a.k.a. Tioumen or Tiumen, a regional subdivision within the Urals -- one of Russia's 7 federal districts), bordering on Kazakhstan : 14 outbreaks (including Vorobyovo village) in 8 settlements in 4 districts (Berdiuzhsky, Armizonsky, Kazansky, and village of Sladkovo in Tyumensky district^ref) and on 7 lakes. Authorities culled all the poultry in 6 settlements and in one settlement the quarantine has been lifted. 30,500 head of chickens, ducks and geese have been slaughtered. Mass die-offs of birds have not been registered. Regional authorities have allocated 6.2 million rubles (about USD 218 000) to curb the spread of the virus^ref
• Kurgan oblast (region) : apparently non-HPAI confirmed in 6 outbreaks in 6 districts (Chistoozerny, Petukhovsky, Almenevsky, Kurtamyshsky, Makushinsky, Lebyazhinsky); 5090 birds were killed. Another 14 settlements in 5 districts are suspected bird flu contacts. The quarantine has been lifted in one of the 21 settlements previously affected by the epizootic. Kurgan oblast, where this outbreak is located, is situated within the Urals Federal District, which is one of Russia's 7 main Federal Districts. In early Oct 2005 there were 3 new confirmed outbreak sites and 3 suspected, which resulted in the culling of > 460,000 birds. On Oct 29 an outbreak occurred in Polovinnoe Village
• Chelyabinsk oblast (region) (Urals region, technically still in Siberia) : 3 outbreaks in 2 districts (Oktyabrsky, Uvelsky). 15 poultry farms in 2 populated areas (60 birds had died in the village of Oktyabrskoye since Sat Aug 13 2005; Barsuchye since Aug 17) have been hit by the bird flu and nearly 500 birds killed. Chelyabinsk, which borders Kurgan on the east side of the Ural mountains dividing European Russia and Asian Russia (and Europe from Asia), is the westernmost region to have been struck so far. It lies about 1000 km (600 miles) from the region where the 1st flu outbreak was reported. 954 domestic birds were culled in the village to prevent the virus, which has killed > 10,000 birds countrywide, from spreading further^ref1,ref2. Mass die-offs in domestic birds have not been noted. Medical observation and quarantine measures in the affected settlements continue. On 22 and 26 Oct 2005 outbreaks occurred in Sunaly Village
• none in Sverdlovsk oblast and in the autonomous districts of Khantia-Mansia and Yamalia. On Oct 31 and Nov 1 outbreaks occurred in Shatrovo village
• Kalmykia Republic (Caspian region, 2000 km (1200 miles) from the region where Russia's 1st flu outbreak was reported; 1800 km south of Moscow and is the only Buddhist region in Europe) : mass bird deaths occurred on a small farm since Aug 17, in what could become the 1st case of the deadly bird flu virus spreading to Europe. The virus could reach the Black Sea and Caspian Sea regions this autumn and speed through European Russia by the spring. The death of poultry in a Bashkortostan village and Kalmykia was not related to bird flu, but rather caused by saline poisoning : the birds were given the fodder intended for cattle by mistake : the Pyatigorsk laboratory provided negative results for avian influenza on the afternoon of 18 Aug 2005. No further details on the tests are available, but it seems that these results are not final: samples have been forwarded for confirmation to the virologic center in the city of Sergiev Posad, near Moscow, the results of which are expected at the end of 22 Aug 2005^{ref1, ref2}. The quarantine has been lifted.
13,724 head of domestic poultry have died since July 21 to Aug 22 in the region's 13 districts and as many as 139,000 heads of  poultry have been slaughtered since July 21 : almost 9 million rubles [USD 315 000] have been earmarked for compensation to the population. In addition, there are reports of the disease in wild birds. There are rumors about the northwestward spread of the disease in Siberia from Novosibirsk to the oblasts (regions, administrative and territorial divisions). The death of poultry in the Kalmyk republic had happened because of helminthiasis.
On Sep 23, 2005 49 Russian settlements in 7 regions have confirmed cases of the bird disease, with another 81 suspected. Quarantine measures have been lifted in 24 Russian settlements.
In the regions of Irkutsk, in eastern Siberia, and Penza, in European Russia, local officials decided to open the hunting season for birds early, hoping that possibly infected wild birds will be shot out of the air, even though there have been no cases of bird flu in those regions.
H₅N₁ has been isolated many times and in many places. In University of Minnesota, researchers isolated H₅N₁ from ducks in 1981 and 1985 and experimentally infected ducks with a duck isolate of H₅N₁. None of these H₅N₁ were in any way related to the current SE Asia outbreak. With the current lack of understanding in the media and general public, the detection (and subsequent "reporting") of a generic H₅N₁ virus or antibody could have devastating consequences related to panic and politics. Authorities in neighboring Kazakhstan have been informed, as the 3 districts lie close to the Kazakh border. The probability that they have the same type of virus is very high, as some birds fly to Russia from China through Kazakhstan. See map. Maria Pashkova, a reporter for the state-owned broadcasting company Novosibirsk, visited the districts of the Novosibirsk Region, fell ill, was hospitalized on Aug 13 2005, and recovered. 4 other Russians were hospitalized with suspected avian flu recently, but all 4 tested negative. The inferred amino acid sequence of the haemagglutinin cleavage site for an isolate from a turkey from the village of Suzdalka is PQGERRRKKR/GL, which is analogous to the sequence of the HPAI found in 3 species of migratory water birds during the epidemic in May/June on Qinghai Lake (People's Republic of China). The nucleotide sequences of the PCR fragments of 2 other regions of the haemagglutinin and neuraminidase sub-units showed highest similarity with the nucleotide sequences of isolates from infected mountain geese and gulls at the time of that epidemic. According to the sequence data, the cleavage site structure is practically identical to that of the highly pathogenic strain of subtype H₅N₁ isolated in Hong Kong in 1997. If this sequence differs significantly from that of the current East Asian viruses, it might indicate that the virus reached Siberia by a different route. Phylogenetic analysis of the preliminary data on the neuraminidase structure shows that it is practically identical to that of the isolate from bar-headed geese (Anser indicus) from the Qinghai Lake region (People's Republic of China)^ref. Transfer of the virus from one village to another has not been established, and spread of infection within villages is slow. Infected localities do not form clusters. There are 2 main reasons for this: 1st, stringent quarantine measures; and 2nd, long average distances between localities (on average 12 km). Practically all the infected localities are close to reedy lakes or marshes used by wild ducks. In these villages, the 1st birds to be affected are those kept in homes close to reservoirs. Not a single poultry plant (large closed commercial poultry plants with > 20,000 birds) has been found to be infected or to contain a seropositive bird for A influenza of any subtype. One infected farm has been identified (a free-range goose farm in Altai Territory with approximately 10,000 birds) and was depopulated the day after the infection was discovered. Human infection has not been established, despite careful monitoring of residents of affected villages, staff of veterinary laboratories and people engaged in the slaughter and disposal of birds. Infection of pigs in the affected localities has not been established. There is still a risk of new outbreaks of the disease appearing in domestic birds. This is most likely to occur during the current period (migration of birds from northern to southern Siberia) and in mid-September (migration of wild water fowl to their wintering grounds). The level of infection of the population of wild ducks and geese is not known precisely, but is assumed to be extremely widespread. In all the places, deaths of wild ducks have been reported. Slaughter of birds in the areas at risk and monitoring of the virus are continuing. During the monitoring and diagnosis process, approximately 32,000 tests have been conducted. The main laboratory screening methods used are the following: haemagglutination test, haemagglutination inhibition test, ELISA (revealing antibodies to NP protein) and PCR (revealing the H₅ gene in tissue and excrement)^ref. The European Commission banned poultry exports from Russia on 17 Aug 2005 due to the bird flu outbreak in the central and eastern parts of the country : representatives of EU veterinary services on Tue 20 Sep 2005 evening voted in favour of introducing a system in which poultry exports would not be banned from the country as a whole, but just from the regions where bird flu was registered. This is a very important decision since it opens the door not just for poultry deliveries, but also provides the possibility to export Russian grain to EU countries : when bird flu is registered in an exporting country, an importing country can ban imports of meat and grain, in particular feed grain, from that country as a safety measure. The decision of the EU to allow resumed imports of poultry from unaffected regions in Russia is based upon the principle of Zoning (or regionalisation). According to article 1.3.5 of the International Animal Health Code, Member Countries may establish and maintain a subpopulation with a different animal health status within national boundaries, namely regionalized and separated by natural or artificial geographical barriers. This may be done for the purpose of disease control and/or international trade. If the EU sanctioned the imports, this might have been based upon data confirming that the current avian influenza outbreak remained restricted to the regions east of the Urals, enabling western regions in Russia to be considered uninfected. Such data will be helpful to the international community; Russia's last follow-up report (No 2) on the H₅N₁ situation was sent to the OIE on 20 Aug 2005
The following is a description of Russia's administrative divisions. All of the federal subjects of Russia ("The Russian Federation") are grouped into 7 federal districts (Russian federalnyye okruga, singular federalny okrug), each administered by a governor appointed by the president of the federation :
• 1.Central Federal District ( Tsentralny federalny okrug). Administrative center: Moscow. Includes: Belgorod Oblast, Bryansk Oblast, Ivanovo Oblast, Kaluga Oblast, Kostroma Oblast, Kursk Oblast, Lipetsk Oblast, Moscow (federal city), Moscow Oblast, Oryol Oblast, Ryazan Oblast, Smolensk Oblast, Tambov Oblast, Tver Oblast, Tula Oblast, Vladimir Oblast, Voronezh Oblast, Yaroslavl Oblast.
• 2. Southern Federal District (Yuzhny federalny okrug). Administrative center: Rostov-na-Donu. Includes: Adygeya Republic, Astrakhan Oblast, Chechnya Republic, Dagestan Republic, Ingushetia Republic, Kabardino-Balkaria Republic, Kalmykia Republic, Karachay-Cherkessia Republic, Krasnodar Krai, North Ossetia-Alania Republic, Stavropol Krai, Rostov Oblast, Volgograd Oblast.
• 3. Northwestern Federal District (Severo-Zapadny federalny okrug). Administrative center: St. Petersburg. Includes: Arkhangelsk Oblast, Nenetsia Autonomous District, Kaliningrad Oblast, Leningrad Oblast, Karelia Republic, Komi Republic, Murmansk Oblast, Novgorod Oblast, Pskov Oblast, St. Petersburg (federal city), Vologda Oblast.
• 4. Far Eastern Federal District (Dalnevostochny federalny okrug). Administrative center: Khabarovsk. Includes: Amur Oblast, Jewish Autonomous Oblast, Kamchatka Oblast, Koryakia Autonomous District, Khabarovsk Krai, Magadan Oblast, Chukotka Autonomous District, Primorsky Krai, Sakha (Yakutia) Republic, Sakhalin Oblast.
• 5. Siberian Federal District (Sibirsky federalny okrug). Administrative center: Novosibirsk. Includes: Altai Republic, Altai Krai, Buryatia Republic, Chita Oblast, Aga Buryatia Autonomous District, Irkutsk Oblast, Ust-Orda Buryatia Autonomous District, Khakassia Republic, Kemerovo Oblast, Krasnoyarsk Krai, Taymyria Autonomous District, Evenkia Autonomous District, Novosibirsk Oblast, Omsk Oblast, Tomsk Oblast, Tuva Republic.
• 6. Urals Federal District (Uralsky federalny okrug). Administrative center:  Yekaterinburg. Includes: Kurgan Oblast, Sverdlovsk Oblast, Tyumen Oblast, Khantia-Mansia Autonomous District, Yamalia Autonomous District, Chelyabinsk Oblast.
• 7. Privolzhsky (Volga) Federal District (Privolzhsky federalny okrug). Administrative center: Nizhny Novgorod. Includes: Bashkortostan Republic, Chuvashia Republic, Kirov Oblast, Mari El Republic, Mordovia Republic, Nizhny Novgorod Oblast, Orenburg Oblast, Penza Oblast, Perm Oblast, Permyakia Autonomous District, Samara Oblast, Saratov Oblast, Tatarstan Republic, Udmurtia Republic, Ulyanovsk Oblast.
As of 5 Oct 2005, the number of towns and villages affected by the outbreak have fallen from 50 to 7. Investigators are conducting tests in 19 other settlements suspected to have the bird flu cases. During the epidemic, the disease has been registered in 50 towns in 6 of the Russian Federation's components, with 83 major cities suspected of contamination. Russia's last follow-up report to the OIE on the avian influenza situation, including a map of the affected regions, was received on 20 Aug 2005^ref. Have new outbreaks been suspected/confirmed? If affirmative, where? In which species? How many avians have been affected, and what control measures have been applied? A fresh follow-up report would help. The latest outbreak was recorded in the Kurgan region in southern Siberia. The outbreak at the Utyatskaya farm in the Kurgan region was the 1st to be recorded in the region, located just east of the Ural Mountains. > 1/5 of the farm's 460 000 birds have died and authorities will likely slaughter the rest. The farm stopped sales on 28 Sep 2005 when the 1st birds died. According to additional information several foci of avian influenza have been registered in other parts of the Kurgan region during August and September 2005, affecting private farms. The current outbreak involves a large integrated farm.
At the request of the Russian authorities the World Organisation for Animal Health sent a team of world-renowned experts in avian influenza and ornithology to Siberia in order to assess the avian influenza situation in the region (see OIE press release of the 4 Oct 2005). One of the main conclusions of the report is that in certain conditions migratory birds could carry the Asian H₅N₁ influenza virus to other parts of the world. The migratory routes of these potentially infected wild birds are mainly directed to the Caspian Sea, the Middle East, and Africa. A few of these birds could rest during the migration or migrate to western Europe. Facing the current and potential evolution of the Avian influenza spread, the OIE confirms its position about the priority of eliminating the virus at the animal source, emphasizing the importance of the early detection and rapid response mechanisms carried out by Veterinary Services in
countries at risk. We will provide a few details of the aims and conclusions extracted from various sections of the report. The conclusions address 2 main issues: surveillance, risk assessment and epidemiology needs(#1-8) and laboratory capabilities and procedures (#9-14). Please consult the report in its entirety for a complete picture
• 1. To assess the situation with regard to the possible relation between infection of wildlife with HPAI of the H₅N₁ subtype and the AI outbreaks in domestic poultry;
• 2. To assess the current capabilities of the Russian reference laboratory and if possible other diagnostic laboratories in the diagnosis of AI
• 3. To submit an independent Mission Report to the OIE on completion of the mission.
The risk of introduction of HPAI by wild birds to Europe : the existence of known migration flyways of several bird species connecting South East Asia, Siberia and Europe shows a possibility of the introduction of H₅N₁virus to both Eastern and Western Europe. The possible continental spread of HPAI H₅N₁ by migratory birds should be under continual review particularly with reference to the results of investigations in wild birds in the republic of Kalmykia since the region (Caspian Sea) is recognised as a significant wintering area for water birds of various origins (Europe and western Asia) and can be
considered a so-called biological hub. In the light of recent developments with the detection of H₅N₁ HPAI virus that is very similar to a virus isolated
from a wild birds in Novosibirsk district in August 2005, in Turkey with further characterisation results from the H₅ virus in Romania, considering migratory bird movement, the spread and introduction of this virus into Europe via wild birds may be recognized as probable.
Conclusions :
• 1. Full and complete analyses according to international standards for H5 and other influenza viruses already isolated from both poultry and wild birds should be given the utmost priority. Information on all H₅ viruses from wild birds sampled before, during and after poultry outbreaks will be critical for national and international authorities in both veterinary and human health sectors.
• 2. Active surveillance and monitoring in wild birds should realized on an international basis and should be focused on specific risk factors and target species:
• - where there is a high density of wintering water birds species and meeting points of several flyways, so called biological hubs
• - high-density poultry areas
• - previously AI-infected areas
• - places of wintering of bird species that spend summer within the affected regions of Siberia.
Experts from the mission are available to provide direct support to developing and establishing such programmes. There may be opportunities to harmonise with such programmes being put in place in Europe.
• 3. Passive surveillance in wild birds should consist of early reporting of unusual mortality in any species. Local hunters and ornithologists should be informed and involved in this process and advised of the importance of such early warning.
• 4. Current attempts at risk assessment suffer from a lack of quantified information on bird migration and on the interaction between wild birds either infected or not infected with HPAI-H₅N₁. To assess the risk posed by migratory birds in transporting HPAI it is necessary to:
• - assess and monitor occurrence of AI in key species at strategic migratory sites and at different times during the migration and breeding cycles of the respective species
• - analyse the cumulative bird ringing recovery data to estimate the importance of the connection between the West Siberian and European bird populations
• 5. Virus strains isolated from domestic and wild birds should be submitted to the OIE/FAO Laboratory Network on AI (OFFLU) and in particular this should involve early sharing of current H₅N₁ viruses isolated in Russia to support international efforts to combat the threats posed.
• 6. A program of active surveillance should be set up in domestic poultry both in backyard and commercial sectors for early detection of infection including in Western Russia.
• 7. The developing and realization of vaccination programs for poultry of backyard farms within the affected regions is strongly recommended.
• 8. Data collection, assimilation and analyses should be streamlined and performed in a timely manner by epidemiologists.
• 9. To improve the diagnostic capabilities of the veterinary laboratories in the Russian Federation the team strongly recommends that:
• - the CVA of the Russian Federation should identify one National Reference Laboratory for Avian Influenza (NRL), which should have all the necessary equipment, reagents and expertise at least to perform standard procedures for screening and characterisation of AI viruses
• - quality assurance programs should be conducted in the laboratory network of Russia under the supervision of the NRL
• 10. OFFLU should provide the NRL of the Russian Federation with reference materials and advice as required to guarantee the reliability of AI tests.
• 11. The roles and responsibilities of laboratories involved surveillance and diagnosis of AI would benefit from being clearly defined to ensure resources are not duplicated or wasted.
• 12. Permanent links must be created between OFFLU and the Russian NRL for avian influenza as soon as possible in order to improve 2-way collaboration, provide training and to exchange technical and scientific information
• 13. A clear laboratory testing strategy in accordance with OIE guidelines should be developed and applied to ensure that laboratory test results critical for advising control and surveillance are available at the earliest opportunity. This should involve the following minimum standards for all H₅ or H₇ viruses in order of priority:
• haemagglutinin subtype identification
• pathogenicity determination
• neuraminidase subtype identification
• selected viruses should be analysed more fully at the genetic level to provide information on molecular epidemiology
• 14. It is strongly recommended that consideration be given to an international audit of laboratory processes to include the management of samples, testing processes, reliability of results, use of facilities, use of data and measures for delivery of results
240 chickens, ducks and geese died suddenly since Oct 14 2005 (but the outbreak had started on 18 Jul 2005) in the village of Yandovka (Jandovka) [Latitude: 53.034, Longitude: 38.399] in the country's Tula region^ref, about 200 km (125 miles) south of the Moscow  in the Central Federal District : the national reference laboratory on bird flu in Vladimir on Oct 19 confirmed HPAI A(H₅N₁) virus. This is the 1st case of avian influenza H₅N₁ in the European part of Russia. The mortality rate within the infected backyard farms was estimated as follows: > 4% of ducks, > 44% of muscovy ducks; > 51% of chickens; > 75% of geese; 100% of turkeys.
The deaths of up to 150 domestic birds (mostly ducks and geese) in the village of Kolundayevsky, about 1,000 kilometres south of Moscow, in the southern Russian region of Rostov are not tied with bird flu, but rather pasteurellosis : a second outbreak in the village of Shabliyevka caused death of 120 waterfowl.
On 18 Oct 2005 bird flu has been confirmed in 2 villages in the Kurgan, while 19 villages in the Novosibirsk and Altai provinces are under observation. 3 other provinces where bird flu was detected earlier -- Chelyabinsk, Omsk and Tyumen -- are now free of the virus.
On 22 Oct 2005 in the village of Sunaly in the Chelyabinsk region in the southern Urals, 33 birds, among them turkeys, ducks, and chickens, have died at 2 individual farms in the village of Sunaly. There are a total of 26 individual farms in the village. Local authorities found bird flu in 6 samples out of 12. All 1060 birds in the village will be killed. A quarantine was imposed from Sat 22. Vaccination of all 89 people in the village will start on Mon 24 Oct 2005^ref
Tambov Region : Ioujnii village, located 400 km (250 miles) south east of Moscow, has confirmed an outbreak of H₅N₁ virus in some dead fowl tissue samples on 21 Oct 2005 : the disease killed 12 hens at a private dacha in Morshansk district, Morshanskogo, on 24 Oct 2005 and 3 Nov, after which local veterinary authorities destroyed 53 ducks and hens remaining in the locality, and imposed a quarantine on it. On 26 Oct 2005 an outbreak occurred in Streltsy Settlement.
Late in Oct 2005, dead migratory waxwings were found in Asbest, outside Yekaterinburg, the Urals. Waxwings belong to Order: Passeriformes, Family: Bombycillidae, Genus: Bombycilla.
Russia has been fighting bird flu since mid-July 2005 and has killed > 600 000 domestic fowl.
According to FAO's update on Avian Influenza No. 35, 5 Nov 2005 (see 20051106.3251), additional outbreaks have been recorded in Russia as follows:
• Ioujnii Village, Tambov Region (21 Oct 2005);
• Sunaly Village, Chelyabinsk Region (22 Oct 2005);
• Morshansk, Morshanskogo, Tambov Region (24 Oct 2005);
• Pokrovka Village, Altai Territory, Sunaly, Chelyabinsk Region and Streltsy Settlement, Tambov Region (26 Oct 2005);
• Novichiha Settlement, Altai Territory Rozovka Settlement, Omsk Region near the border with Kazakhstan (27 Oct 2005);
• Polovinnoe Village, Kurgan Region (29 Oct 2005);
• Grjaznova Village, Altai Territory and Shatrovo Village, Chelyabinsk Region (31 Oct 2005);
• Shatrovo, Chelyabinsk Region (1 Nov 2005);
• Morshanska, Tambov Region (2 Nov 2005)
• Novosanzharovka, Omsk Region (3 Nov 2005)^ref
For a time-line on bird-flu in Russia^ref. The outbreak in wild swans in Astrakhan (the Volga delta, bordering Kalmykia on the west, Kazakhstan on the east and the Caspian sea on the south), was not included in the above list because it did not affect domestic fowl. The event was published by CNN on 23 Nov 2005: "....Meanwhile, Russian veterinary authorities said Tuesday [22 Nov 2005] that bird flu had been detected in a southern region and that measures were being taken to prevent it from spreading, AP reports. The country's veterinary service identified the H₅ type of bird flu in 200 swans that were found dead in the Volga River delta in the Astrakhan region, the Agriculture Ministry said. It had not yet been determined whether it was the H₅N₁ strain^ref. Final results of laboratory testing of the swan material will help. Astrakhan has suffered recently cases of West Nile fever; West Nile virus is known to be spread by migratory birds and several years ago caused a major outbreak in Romania. Romania and Croatia reported cases of HPAI H₅N₁ in wild swans during October 2005. The Croatian notification to the OIE mentioned 1500 wild migratory swans, of which 15 birds died. The mute swan is to be found extensively across Europe, Asia, North America, South Africa, Australia and New Zealand. Northern populations in Europe might migrate to and winter in warmer areas in the northern Levant and the Black & Caspian Seas. It will be interesting to obtain information on recent seasonal movements of mute swans into and from these areas, and results of epidemiological and virological surveillance in this species, if undertaken.
Almost 715,000 birds have died from bird flu in o regions of Russia since July 2005 to Jan 2006 or been culled in an effort to stem the spread of the virus. The 1st wave of avian flu swept through 6 Russian regions of the Volga and Urals federal districts from 21 Jul to 29 Sep 2005. The 2nd outbreak was registered on 14 Oct 2005 in 5 regions of the Central, Volga, Urals and Siberian federal districts.
No new outbreaks have been reported in poultry since late December 2005. Dead pigeons were found in Leninsk District, Murmansk Oblast : samples from all poultry farms in the area were sent to the laboratory in St. Petersburg, with negative results. Antibodies against AI have been detected in 2 workers out of 450 that have been sampled in 15 poultry-farming facilities in the Rostov Oblast. On Fri 17 Mar 2006 evening some 2.65 million doses of bird flu vaccine were delivered by plane from Moscow to the Rostov region : all in all, 8 million domestic birds will be inoculated in the Rostov region, through which birds migrate. The next phases of the inoculation are planned for March 31 and April 14^ref.
On Sun Feb 26, an official of the Russian Agricultural Ministry said bird flu virus had been detected in wild fowl, including migratory birds, in 6 Russian regions in southern Russia : in 4 of those regions, the virus affected domestic poultry^ref
• Republic of Kabardino-Balkaria
• Republic of Kalmykia : 96 birds died at the Komsomolets poultry farm in Kalmykia, which has 900 birds, and a quarantine has been imposed^ref
• Republic of Adygeya : H₅ was identified  in an affected village; final identification of the virus is pending. Samples were sent to the reference laboratory.  All chickens at this village were destroy
• Stavropol territory : 5 outbreaks :
• Izobilnensky district
• Shpakovsky district : on 22 Feb 2006 > 2000 hens at a private farm in the village of Nadezhda and other 2 places. All infected birds were destroyed. 42 Nadezhda residents have been inoculated against bird flu and another 43 have undergone medical examinations. No bird flu cases among humans have been reported in the village^ref
• Neftekumsky district
• near Kislovodsk town
• on Sat 11 Mar 2006 tests conducted by a laboratory of the Animal Protection Institute in the city of Vladimir have confirmed that birds in the Bogoslovskaya poultry farm^ref (where > 70 000 chickens out of 120 000 died and the rest were killed) in the Stavropol Territory were infected with H₅N₁^ref
• Krasnodar territory : on 13 Feb 2006, avian influenza was confirmed in village Zlatoust, Cheliabinsk region (Ural Oblast). Authorities began preparation for mass vaccination of birds. AI has been detected in storks and wild ducks in the Krasnodar Region shore (in southern Russia) : according to Xinhuanet of  24 Feb 2006, > 102,000 poultry deaths were reported at Tbilisskaya farm in the southern Russian area on Thu 23 Feb 2006 : H₅N₁ was confirmed on Feb 28^ref. The flare-up of bird flu started at the poultry yard in question on February 22 where it had 300,000 chickens at that time. Out of the total, 100,000 already died and were destroyed^ref. On Feb 27, a commercial poultry farm in the village Lavlinskaya, Krasnodar region, where 39 000 hens died, was found to be infected with Newcastle disease by the regional laboratory. Samples have been sent for confirmation (and to exclude avian influenza) to the Russian reference laboratory at Vladimir^ref
• Daghestan^ref, Russian Caucasus (an area close to Turkey and across the border from former Soviet Azerbaijan) : on 15 Feb 2006, deaths of chickens due to H₅N₁ were reported in a breeding farm in Makhatchkalinskaya, Chamkhal village in Shamkal, where 196,000 poultry have died (42,467)/been culled out of the 275 000 chickens housed before the outbreak : the Sun 12 Feb 2006 death toll was 4067. On Feb 18, H₅N₁ avian influenza was confirmed in Eldama in the Karaboudakhkent area (40 km away from Makhachkalinskaya) where 350,000 poultry have been lost between 25 Jan and 1 Feb 2006^ref : on 3 Feb 2006 the outbreak had been attributed to Newcastle disease^{ref1, ref2}. Bird deaths have been registered at farms and in villages in 14 districts (Kaspiysk, Buynaksk, Kizlyar, Hasavyurt and Machachkala, Karabudahkent, Babayurt, Derbent, Tabasaransk, Charodin, Tarum, Magaramkent and Laks^ref) : dead domestic birds have been found on the Derbent, Tarumovka and Kizlyar districts. A total of 561,987 domestic birds have died of avian flu H₅N₁^ref
• Chechnya : wild ducks and swans were found dead on Feb 15^ref. Recently, the virus has been found in wild swans and wild ducks in the littoral zone of the Krasnodar region^ref
• Volgograd region (Oblast) (situated within Russia's Southern Federal District (Yuzhny federalny okrug)^ref) : dozen of dead birds tested positive at a farmyard at the village of Vesyoly in late Mar 2006. Preventive work including disinfection is being carried out and 2 million doses of bird flu vaccine have been sent to the province from Moscow^ref. 25 birds died on Tue Apr 11 in the village of Kolobrodovo, in the Frolovo district [Lat 49.7897, Long 43.4447^ref], and tested positive for H₅N₁^ref
• Altai Territory : 1 duck shot on Lake Shuga in the Uglovsky district, and 4 ducks from Lake Gusinoye, Khabarsky district, tested positive for H₅N₁ on May 2006^ref. After 168 hens, ducks, geese and turkey cocks died in May 2006 in 6 small farms in the village of Troitsk, the Kulundinsk district of the Altai Territory, 4 out of 14 blood serum samples tested positive for H₅N₁ virus^ref
• Novosibirsk region, Siberia : found in non-vaccinated poultry in private households of the Reshety village [Latitude 54.2142 Longitude 80.2142^ref], in the Kochkovo district on May 10, 2006. So far the flu has killed 64 birds. The village has 35 000 poultry^ref
Provisional laboratory tests of fowl that died on 2 Mar 2006 in the southern Astrakhan Region, home to > 1 million people, had found antibodies to both the H₅ bird flu strain and Newcastle disease, which means that birds were infected either with one virus or both of them. A total of 768 533 have died or been culled in Southern Russia since 3 Feb 2006 to 7 Mar 2006. Over 1.3 million birds have died or been slaughtered in 3 outbreaks of bird flu since July 2005, including > 416,000 birds that died from the virus^ref. Russia's last (5th) update on HPAI was sent to the OIE on 27 Dec 2005^ref.  It presented a summarizing table of all 62 outbreaks in 10 regions that had been recorded until that date. Stavropol, in south Russia between the Black and the Caspian seas, was not included at that time^ref. Russian authorities have commenced the mass vaccination of the whole country's poultry stock^ref
On Wed 14 Mar 2006, 30,000 birds died in a 24-hour period in southern Russia -- including almost 22 000 in the Krasnodar region with the rest in Daghestan^ref. So far, > 350,000 birds have died of the disease or been culled in Krasnodar and 760 000 in Daghestan^ref.
In 2005 Russia lost 662 000 heads of poultry, which died or were slaughtered : in 2006 (as of Mar 21) the figure is 1.3 million poultry. In 2005, the virus affected 62 towns in 10 Russian regions, while since the start of 2006, already 56 towns in 9 regions have been affected. In 16 of the towns, infected birds have been slaughtered, but the virus is still present in the other 40. 32 million vaccine doses would be produced in Russia by the end March 2006, 42 million in April 2006 and 70 million in May 2006 with the aim of a production peak of 1.2 billion annually. Demand on the Russian poultry market dropped by 20-25% between November 2005 and March 2006 because of the bird flu scare^ref
A significant number of dead wild ducks have been found in the River Ikortes in the Voronezh region south west of Moscow, according to the region's chief sanitary officer. Samples have been taken for tests^ref.
On Apr 14, 2006, a criminal investigation has been launched into the activities of 2 villagers from Russia's Saratov region, who decided to make money by playing on the fear of a bird flu pandemic. They used milk instead of vaccine to inoculate birds, earning USD 1.70 per injection^ref. Unusual winter weather patterns in southern Russia, Turkey, and Iran have forced many migrating birds to nest in unlikely places, explaining early outbreaks of the deadly H₅N₁ strain in the southern region of Dagestan and other places. > 1.2 million wild and domestic birds had been culled in February 2006 in an attempt to limit the spread of the disease^ref
As of 5 May 2006, 7 zones out of a total 80 locations where outbreaks have been recorded in 2006 were still affected: all the contaminated districts are in the south of the country, in the provinces of Volgograd, Krasnodar and Dagestan^ref. 32.9 million birds had been vaccinated against bird flu on farms and production facilities^ref
• Omsk region : 86 dead chickens found in the village of Maksimovka the between 29 Apr and 13 May 2006 were infected with H₅N₁, similar to chronologies of 2005^{ref1, ref2}. On 16 Jun 2006, H₅N₁ was found in dead birds in the village of Aleksandrovka : in all the 5 settlements in Omsk regions, where mass die-off of birds caused by influenza virus A/H₅N₁ has been registered, the quarantene has been lifted; from Poltavka on 6 Jun 2006, from Maksimovka 9 Jun 2006, from Novobelozerovka 14 Jun 2006, from Bobrinka 18 Jun 2006 and from Karan-Goral on 19 Jun 2006^ref.
• Altai Territory : unvaccinated fowl infected with avian influenza have been registered in 1 village^ref
• Tuva Republic : since 15 to 26 Jun 2006 1622 dead wild birds were collected from the Ubsu-Nur Lake in the Ovyursky district, and the presence of H₅N₁ in their blood samples had been confirmed by the Kemerovo veterinary laboratory, but since 50 fish started dying first and apparently contaminated the birds through the food chain, Vladimir Zabelin, a leading local ornithologist, said contamination of Tes-Khem River flowing into the lake could have been to blame^{ref1, ref2, ref3}. The Republic of Tuva (170 500 sq km: north to south 420 km, west to east 630 km; 1990 est. pop. 366 000) is situated in the center of Asia in the south of Eastern Siberia, bordering Mongolia in the south, Irkutskaya region in the northeast, the republic of Khakasia in the northwest, the republic of Buryatia in the east, the republic of Altai in the west and Krasnoyarsky region in the north^ref.
• Altai Krai : in 2 settlements; the villages of Troitsk and Plotava where mass die-off of birds were registered from 19 to 27 May 2006, the quarantine has been lifted. Settlements with an unfavourable situation when it comes to avian influenza are not registered in the region.
• Novosibirsk region : in 3 settlements; Resheti, Kochki, and Lyagushe where mass die-offs of domestic birds were registered from 3 to 17 May 2006, the quarantine has been lifted. Settlements with an unfavourable situation when it comes to avian influenza are not registered in the region.
• Kazakhstan (population exceeds 16 million; according to FAO statistics, in 2005 the egg-production industry exceeded 13 million laying hens) : on 31 Jul 2005 a 20-year-old man, a poultry farm worker from the village of Golubovka, Irtysh district, Pavlodar region, showing bird flu symptoms has been hospitalized after 400 domestic ducks and geese died between 22-30 Jul 2005 as a result of an outbreak of the disease at a farm in the village housing 2800 birds (2350 geese and 450 ducks). Officials slaughtered 2400 birds (2350 geese and 250 ducks ?) at the farm. Samples sent to Kazakhstan's National Veterinary Center in Astana to establish a final diagnosis confirmed HPAI A(H₅N₁) virus on Aug 12^ref. Pavlodar is situated in north-eastern Kazakhstan, bordering south-western Siberia, a region where at that epoch an outbreak of H₅N₁ was ongoing. Golubovka, is on the river Irtysh. This and other major rivers in eastern Kazakhstan run northwest into Siberia. The outbreak hints that the disease is moving towards Europe. Over the past 3 months, > 6,000 birds have died at Qinghai Lake in China, in the first major outbreak of H₅N₁ in migratory birds^ref. This has raised fears that birds might spread the virus worldwide, with eyes in particular on those that will fly from their breeding grounds in Qinghai to destinations across southeast Asia and India later this summer. The WHO has called for samples in Russia and Kazakhstan to be tested at its laboratories. They hope to sequence the virus and compare it to viruses from Qinghai, as well as those circulating in Southeast Asia. It is unlikely that the disease has come to Russia from China, as birds do not usually fly in that direction at this time of year : the new cases might have spread from undeclared poultry outbreaks in nearby China, but there is still cause for concern over migratory birds. The best thing to do would be to set up surveillance areas to randomly test wild bird populations. The FAO would need US$20-30 million for such a study. Some 364 hens have died in a village in the eastern Kazakh region on Aug 6, while 37 wild ducks have been found dead at the Vinogradovka lake in the Akmola region, where 70 hens and 30 ducks living on private farms that may have been in contact with wild ducks had been destroyed : 345 poultry had been culled. The deaths of 364 hens in the village of Krasny Yar, initially assumed to having been caused by bird flu, turned out to be due to a regular bird disease. On 8 Aug 2005 the European Commission banned import of feathers and live birds from Russia and Kazakhstan^ref. Poultry mortality was registered in the Yesil region, Talapker village, of North Kazakhstan oblast (province) (west of Pavlodar) on 12-16 Aug 2005 : antibodies against bird flu have been detected in the tested samples and 678 birds have been eliminated. Bird flu outbreaks had previously been discovered in 5 regions of northern and central Kazakhstan. Over 9000 birds have been slaughtered in Kazakhstan to prevent the disease from spreading further. The Republic of Kazakhstan, in central Asia, borders on Siberian Russia in the north, China in the east, Kyrgyzstan, Uzbekistan, and Turkmenistan in the south, and the Caspian Sea and European Russia in the west. It is the 9th largest country in the world: about 1,050,000 square miles (2,719,500 km²), almost 4 times the size of Texas, with a population (as of 1995) of about 17.4 million. Kazakhstan is administratively divided into 14 provinces (oblasts) and 3 cities. In September, migrating birds escaping the Russian winter might carry avian influenza across the Black Sea and into southeastern Europe and North Africa.

On 22 Aug 2005 the Netherlands ordered poultry farmers to move their operations indoors to reduce the risk of exposure to wild birds and help contain any outbreak : the Dutch reversed the decision on Sep 2005 after advice from migration experts and an EU warning that the eggs and meat would not be able to be sold as free-range if the ban continued beyond 6 weeks. Instead, the Dutch agreed to targeted "farm-by-farm" measures, including temporary roofing for holdings on bird migration routes. The Netherlands is one of the world's biggest meat exporters : in 2003 it had to cull about 1/4 of its poultry after an outbreak of bird flu. Germany plans to follow suit by ordering that all free-range birds be moved indoors by 15 September 2005 to prevent contact with birds arriving from the East that may be carrying the virus, but the new rules were not being put into immediate effect : however, Germany's state governments have the power to order such bans if they wish and the states of Lower Saxony and North Rhine Westphalia have both issued orders that farmers keep poultry inside from September 15 in several parts of their regions used by especially large numbers of migratory birds. But health leaders from Canada and the USA insisted on 23 Aug 2005 that moving poultry flocks indoors doesn't guarantee their safety from deadly avian flu strains and may actually make them more susceptible to illnesses, given that infectious diseases often sweep through poultry operations where flocks are raised entirely in chicken houses. On the other hand, biosecurity measures, including control upon movements of humans, fomites, and particularly live birds and their products, are of essential importance. It will be interesting to follow the decisions obtained during Aug 26 deliberations in Brussels. The British government is sending 50-page pamphlets to doctors with information on dealing with any human outbreak. Some 850 000 migrating birds reach Britain later in the autumn every year, including the mallard and pochard ducks that are thought to have brought the disease from Asia to Russia^ref. The Australian Government has plans to seal off the country from the world, closing air and sea ports, in the event of an Asian bird flu outbreak. Its contingency plan also calls for compulsory quarantine, closing schools, public transport and places of work. Cockfighting is widely practiced in Kazakhstan, as elsewhere in Central Asia, and there is a particularly relevant regional variation on cockfighting that involves pitting freshly captured wild songbirds against each other, who are often held by threads while they fight and may then be released once one emerges dominant. Wild bird fights often occur in the same pits as cockfights, so if you have infected gamecocks, wild bird fighting offers a quick avenue for potential transmission to wild birds at large. A total of 13,438 fowl had been culled. The 10 wild ducks, gulls and other birds found dead in a nature reserve in southern Kazakhstan had actually died from a different bird disease which was not dangerous. On 20 Mar 2006, in its first instance of H₅N₁ infection since July 2005, Kazakhstan has reported that a wild swan found dead on the shores of the Caspian Sea died of avian influenza. Kazakhstan vaccinated approximately 8 million domestic birds and fowl before the swan was found. There have been no reports of further measures taken by the authorities in response to this latest finding^ref. The deadly H₅N₁ bird flu strain has been found among dead swans in western Kazakhstan^ref. Cases of H₅N₁ have been confirmed by laboratory tests in a dead wild bird from the Caspian shore in Mangistau province : as of Wed Mar 22, 32 800 domestic fowl have been vaccinated. Vaccination is under way in another western province, Atyrau^ref, which is believed to be vulnerable to the virus. Some 40 000 doses of vaccine have been provided for that purpose^ref. 3 cases of avian influenza in wild swans occurred at Cape Peschannyi, Mangghystau^ref
• Iran : since 2 Oct 2005 3673 migratory wild waterfowl (wild ducks) died on the coast of Aras River (bordering Nakhjavan), Poldasht, West Azerbaijan (Azerbayjane Gharbi) province. No pathological agent has been identified yet. No postmortem lesions are seen in dead birds; weakness and death are the only evidence. The following tests were done for avian influenza virus subtypes H₅, H₇, and H₉ and all the results were negative. West Azerbiajan is nestled between the borders of Turkey, Armenia, and Azerbiajan. While we are happy to have the negative tests for AI, it would be very helpful to know more about the geography of this outbreak in relation to the migratory wild bird pathways and the other outbreaks in the region (Romania and Turkey have been confirmed to be H₅N₁). A definitive diagnosis of what is killing these birds would be most helpful, or a negative H₅N₁ from a world reference lab would be useful in solving this unknown outbreak : this outbreak was finally diagnosed as botulism. Since Wed Jan 11, 2006, authorities have started destroying

poultry in villages within 15 km (9 miles) of the border with Turkey : 50,000 poultry were destroyed in a few days. Elsewhere, intensive care units had been fully briefed and medical staff given doses of oseltamivir, though he admitted this might not do much good^ref. On 2 Feb 2006, within the framework of the Avian Influenza Passive Surveillance Plan in place for wild birds in Gilan province, a few deaths were reported among swans (Cignus cignus) in 2 marshes (Selkeh and Espand / Wetpand) at Somaesara district (Anzali wetland), Rasht province. Immediately, all the relevant activities were implemented in accordance with OIE guidelines and recommendations, and all of the indigenous birds in 6 villages considered to be epidemiological units at risk (i.e. within a 2-km radius) were destroyed and their owners compensated by the IVO^{ref1, ref2}. One of the most significant changes in the ecosystem of Anzali wetland is that the population of swans has increased from 8 birds in 2005 to 3000 birds in 2006. On Feb 14, 2006 Iranian officials say laboratory tests have confirmed H₅N₁ killed 135 swans from wetlands near the Caspian Sea port of Bandar-e Anzali on Iran's northern coast, a wintering spot for many wild fowl from Russia^ref : if international tests confirm the birds died of the H₅N₁ strain of the virus, it will be its first appearance in Iran^ref. On Feb 19, tests on > 100 dead swans found in wetlands in the northern province of Gilan showed the presence of H₅N₁^ref. Protection and surveillance zones have been established, and on-farm biosecurity measures in all poultry holdings (native, industrial) around the wetland have been intensified. Movement control of poultry products has been enforced. Check points have been established to control illegal movement. Disease awareness among poultry owners has been increased. Live bird markets and other gatherings of birds as well as hunting have been prohibited. All native birds in 6 villages in a 2-km Protection Zone around each outbreak site were destroyed and [their owners] compensated by the authorities. On May 22, 2006, 5 people in Kermanshah city, Kermanshah province, west of Teheran and on the borders with Iraq, were hospitalized after returning from a trip to the town of Marivan, among them a woman and her husband, who have died : there are suspicions of bird flu symptoms^ref. Tests in Iran on the dead bodies of a 41-year-old man and his 26-year-old sister showed they had the lethal H₅N₁ strain of bird flu^ref . Iran's Health Minister on Tue 23 May 2006 denied that tests on 2 dead staphylococcal pneumonia patients had shown they had the deadly H₅N₁ bird flu virus and insisted the results were negative : the fate (or existence) of clinical material sent abroad for confirmation of the local diagnostic tests is obscure^ref. A senior medical official told Reuters on condition of anonymity that preliminary tests in the northwestern city of Kermanshah showed a 30-years-old man died on Wed May 24 morning from H₅N₁ bird flu, considered the 3rd death : Iran's Health Ministry said on Sat 27 May 2006 the country had no human cases of the deadly H₅N₁ bird flu virus, dismissing statements^ref
• Afghanistan^{ref1, ref2, ref3, ref4} (34 provinces) : 5 swab samples from backyard poultry farms in Kabul and the eastern city of Jalalabad in Nangarhar province [near the Pakistan border] tested positive for H₅ in Venezia, Italy on Mon 13 Mar 2006^ref, and H₅N₁ was confirmed on Mar 16. Between 2-19 Mar 2006, outbreaks have occurred in chicken, turkeys and a crow in the following locations^ref: Jalalabad - 5 outbreaks, Kabul - 6 outbreaks, and one outbreak each in Laghman, Vardak, and Kunar provinces^ref. Another 6 samples from Kandahar province in the south and Kunduz province in the north had tested negative^ref. 3 children from the central province of Ghor, which has not reported any suspected cases of avian flu in chickens, died on Mar 30 (?) because of respiratory infection. The children had been buried and no samples had been taken^ref. The lack of samples left investigators to rely on bird samples. Officials found no evidence of disease among about 1000 chickens in the village. However, 20 other samples from 7 provinces have tested positive for an H₅ avian flu, although the neuraminidase has not yet been determine. Results of tests on 103 samples sent to Italy earlier in April 2006 arrived on Mon 24 Apr 2006 and showed that Kapisa province to the north east of the capital, Kabul, is also affected by the disease. The virus had been found already in samples from birds in Logar and Nangarhar provinces. Strong suspicions on Parwan province^ref
• Iraq^ref has some 550 commercial flocks^ref.
• Erbil province : in mid October 2005, deaths of birds were reported in chickens in a poultry farm in the northern Iraqi Kurdish city of Erbil^ref, near Khabat, Kurdistan. Samples were taken from the chickens, and the preliminary analyses were positive for AI. Further testing was done in Egypt on 29 Oct 2005, and H₉ virus was confirmed.
• Baghdad province : between 12 and 27 Oct 2005, hundreds of dead birds were reported in Dora, Sha'ab and al-Ghazelyia districts. Samples have been sent to the WHO regional laboratory in Cairo for testing^ref.
• Sulaimaniyah province, Kurdistan :
• Raniyah district^ref, 100 km south of the Turkish border and just 24 km west of the border with Iran (near the Iranian city of Piranshahr). Raniya lies north of Lake Dukan, a heaven for migratory birds flying south from Turkey^ref.
• Sarkapkan village : 450 backyard birds (chickens, geese, turkeys and ducks) died (and the remaining 1,500 were culled) since 18 Jan 2006. An outbreak in humans occurred at the end of Jan 2006 in Raniyah :
• a 14-year-old girl (Tijan (Shangen) Abdel-Qader) from Sarkapkan fell ill in her home town on 2 Jan and died on arrival at the hospital in the Kurdish city of Sulaimaniya on Tue 17 Jan 2006 after falling ill 15 days earlier. An initial autopsy found no evidence of bird flu and blood samples tested negative in a laboratory in Baghdad on Jan 19 (final diagnosis unknown)^ref. All from her family are well. The girl's family apparently kept chickens in their house, and 18 of those birds also died. Samples tested positive at a U.S. Navy Medical Research Unit (NAMRU) laboratory in Cairo on Jan 30. The girl's mother rejected the bird flu results, but acknowledged that a number of her chickens had mysteriously died. "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". Another press source referred that she had an aortic aneurysm and a history of cardiac problems. The girl's mother rejected the bird flu diagnosis, but acknowledged that a number of her chickens had mysteriously died before her daughter's death^ref
• her 39-years-old uncle (Hamasour Mustapha / 40-yrs old Hamma Sur Abdullah^ref), who cared for her during her illness and who lived in the same house in which live chickens were brought to protect them from the cold, developed symptoms on 18 Jan 2006 and died of a severe respiratory disease on 27 Jan 2006 : his samples have been sent to Jordan for testing^ref, and the Cairo lab confirmed H₅ on Mon 6 Feb 2006^ref, assumed by WHO on Feb 17^{ref1, ref2}
• Dawaw village : 200 birds died (and the reamining 1,000 were culled)
• a 54-year-old woman from the same area was taken to hospital with respiratory problems on Jan. 18, was treated^ref, and recovered what actually was regular flu^ref
A total of 3 commercial farms were affected with a high mortality rate. Control measures implemented include stamping out, quarantine of the premises, disinfection, movement control, surveillance, compensation of culled poultry, establishment of check points and market restriction. Authorities started a campaign to kill birds in 3 towns Raniya, Dukan and Qaladaza.
• Jao Khaled village : 250 poultry have died
At least 200 000 chickens had been slaughtered in Sulaimaniya Province, in the north, and also in neighbouring Erbil Province. Officials in Sulaimaniya said on Tue 31 Jan 2006 that they were treating 14 patients with pneumonia suspected of having contracted AI : on Feb 6 the WHO team said there were 7 suspected cases undergoing treatment^ref. 5 people were released Tue Feb 7 after their health improved following treatment, including Sabria Mohammed, a 40-year-old woman, was a carrier of H₅N₁ but her health improved after she was treated with oseltamivir^{ref1, ref2}. On Feb 19, 13 new suspected human cases of H₅N₁ virus infection in the southern Governorate of Missan and 12 in Sulaimaniyah in northern Iraq^ref.
• Maysan province : authorities have declared a HPAI alert after birds suspected of possibly having avian influenza were discovered in at least 5 parts of the province, which borders Iran and called for security forces to prevent people carrying birds in and out of the southern region.
• Missan province : another H₅ outbreak was reported on 7 Feb 2006 in pigeons in Sahat Al-aradate village, Amarha District, and later confirmed as H₅N₁. Since 18 Jan 2006 2 pigeons died and the remaining 978 were culled after tests showed H₅N₁^ref
• Kirkuk, just south of the Kurdish provinces : rumors are rampant of avian flu cases being covered up by the local government and the price of a chicken has plummeted to a mere 500 dinars (0.33 dollars)^ref.
A massive program has been launched to cull birds in Kurdistan, in border regions north of Sulaimaniyah near Lake Dukan, in Raniya and also north of Arbil. Since 15 Jan to 2 Mar 2006, nearly 1.6 million birds have been killed by health officials in Sulaimaniyah and Missan (30-50% of total birds in different areas)^ref. "We don't have more than 30 pills (enough to treat 4 patients) left in our pharmacies to treat suspected cases, and each patient requires huge amounts of tablets for treatment to be effective," said Tahseen Namiq, a senior official at the Kurdish Ministry of Health on Feb 1. On Fri 3 Jan 2006, the WHO said a shipment of Tamiflu is being sent to Iraq with enough doses to treat up to 10,000 people^ref. On 31 January, Iraq's central health ministry sent 5 ambulances to Sulaimaniyah governorate to help transfer suspected cases and medicines to hospitals^ref. In Zakho, an Iraqi Kurdish frontier city a few km from both the Turkish and Syrian borders, all poultry were being slaughtered and burned. A 900 kilo consignment of masks, gloves and gowns is on its way from the USA to help the war-torn country fight a deadly outbreak^ref
• a young man in the southern city of Amara was admitted to a city hospital suffering from the flu but was discharged after 5 days and subsequently died at home on Sun 5 Feb 2006. He owned 2 pigeons with that were shown infected with H₅N₁^ref, but he tested negative^ref
• Iraqi doctors are investigating 6 suspected human cases of avian influenza in southern Iraq, including :
• a 25-year-old fisherman had contact with birds he was keeping in his yard, developed fever on Feb 6, was admitted to hospital with high fever and a cough, but X-rays showed no pneumonia. 2 weeks after the fever began, the man had difficulty breathing, and his white blood cell count rose sharply and died on Feb 12
• 5 of the fisherman's cousins, who had all been living with him in the city of Amara and had also come in contact with the birds in his yard, are also being tested.
A positive result would show that the H₅N₁ virus had spread to the impoverished Shiite heartland of southern Iraq, where the quality of communications and health care is much lower than elsewhere in the country^ref.
• a fresh suspect human case is under investigation in Diyala province in the north, where chickens died on Feb 20-27 of the H₅N₁ virus^{ref1, ref2}
Samples from an initial 15 patients under investigation for possible infection were tested on Feb 17 at a US Naval Medical Research Unit located in Cairo, Egypt. Apart from the 39-year-old fatal case, all test results were negative^ref. The U.S. Navy laboratory is working through > 100 human samples from Iraq and > 24 samples from birds and cats^ref. Naeema Al-Gasseer, WHO representative for Iraq, said that initial errors in Iraqi hospitals -- including liberally dispensing Tamiflu capsules "like chocolate" to suspect cases -- had been overcome and that Iraq had responded well to the initial crisis given the problems there^ref. On Tue 28 Feb 2006 :
• ? from 2 villages in the town of Kefry, in the north eastern province of Dayala, northeast of Baghdad^ref : the outbreaks prompted the killing of infected poultry and the sterilisation of villages. One other suspected patient in Dayala province was sent to the health centre in Said Jabir village^ref.
• a woman has died in a suspected case of the deadly bird flu virus H₅N₁ close to the town of Nassiriya in southern Iraq. Further tests are being carried out in Baghdad and Cairo^ref
• 3 suspected human cases in the Shula area of Baghdad are still under medical care, with laboratory results yet to be received
Meanwhile, samples tested from 50 suspected patients in the northern city of Sulaimaniyah and Missan governorate in the south were confirmed negative^ref
• Kuwait : 2 cases of AI in birds that came from outside Kuwait were detected on Nov 10 2005, the first in the Gulf Arab region, and were culled. On Nov 11 the falcon imported into Kuwait and discovered at the airport tested positive for H₅N₂, while a migrating greater flamingo, Phoenicopterus roseus, found on a Kuwait beach tested positive for H₅N₁. This species is the only flamingo recorded in Kuwait, and has the most widespread distribution of all flamingo species. Populations are found in northwest India, the Middle East, the western Mediterranean and Africa. Limited numbers can be found over much of northern Europe, eastward to Siberia. Though generally regarded as non-migratory, populations that breed in lakes that may freeze over in the winter, move to warmer areas, and return in springtime. When flamingos migrate, they do so mainly at night and can travel approximately 600 km (373 miles) in one night at about 50 to 60 kph (31-37 mph). Greater flamingos were among the birds clinically affected by H₅N₁ in the Penfold Park, Hong Kong SAR, in November 2002. The Directory of Wetlands in the Middle East lists 2 coastal sites in Kuwait where greater flamingos have been recorded^ref. Ringing (banding) of greater flamingos at Lake Rezaiyeh, Iran in the early 1970s provided considerable information on movements. These are summarised by Argyle (1975) and Scott (1975). Birds banded at this site were subsequently recovered from widely dispersed locations, ranging from Turkey, Libya, Syria and Iraq, to Sudan and Ethiopia, and to Pakistan and India. There were no recoveries from Kuwait, but birds were recorded from Dubai, Bahrain, and Oman. Scott noted that 7 adult flamingos ringed at the Lake Tengiz colony, Kazakh SSR, and 2 ringed on migration at Gasan Kuli Reserve, Turkmen SSR, had been recovered in Iran. Regarding movements of juveniles he noted: "The scatter of recoveries indicates that, rather than following well-defined migration routes, young flamingos undertake an extensive dispersal, generally southwards". It would be of interest to know the age of the bird found dead -- as with all reports of wild birds found dead (Argyle F. Report on bird ringing in Iran 1970 to 1974. Tehran: Department of the Environment, 1975; Scott DA. Iran. In: Kear J, Duplaix-Hall N (editors). Flamingos. Berkhamsted: Poyser, 1975: pp 28-32). Looking at the image of the flamingo in the Al-jazeera news article, it seems clear that at least some flamingo are kept and traded as pets in either Kuwait or the wider region. This combined with a dead imported falcon found at the same time in Kuwait (after apparently bird imports were banned...) suggests something is not quite right with this story^ref. It would seem very useful to try to find out how widespread importing or trapping and keeping of pet birds is in Kuwait, and whether such species include flamingo; whether the beach was indeed a beach (most flamingo feed in shallow saline lagoons, with one key site in Kuwait for greater flamingo appearing to be the Jahra East sewage outflow area -- not exactly a beach area, and one reached by a long drive down semi-closed tracks); and how the bird was actually "found" (dead or alive for example, might provide some useful insight; in a populated or a remote area is another). I believe that there is a specialised working group on flamigoes, and also know that the Wetlands and Wildfowl Trust in the UK have much information on flamingo as well as other waterbird species, their ecology and their distribution. The greater flamingo (accurate Latin name Phoenicopterus ruber) is very migratory. Flamingos migrate during the day -- this is known from the soaring bird migrations conducted at Eilat since 1977. Note that they are also known to breed in India and Iran, such that the Kuwait bird could be from the east or from Turkey to the north.
• Bahrain : dogs and cockerels are being brought from Southeast Asia to take part in illegal fights : most dogfights and cockfights take place in Muharraq, Riffa or Manama. Smuggled animals are thought to be coming across the King Fahad Causeway from Saudi Arabia or slipped past customs officers at Bahrain International Airport. One of the reasons they are thought to come from Southeast Asia is a perceived lack of regulations and enforcement at the airports in that part of the world. Not all animals smuggled into Bahrain are brought here to fight -- they are also brought here to be sold as pets. The problem we are also facing is the smuggling of wild animals into Bahrain for trade. The animal shops in Bahrain are not subject to any form of control or hygiene standards^ref.
• south Yemen : chicken in the province of Al-Kabita
• Saudi Arabia : the 1st confirmed case of avian influenza subtype H₅N₁ in Saudi Arabia, probably in December 2005, involved a saker falcon (Falco cherrug)^{ref1, ref2} that had been in the country for the past 2 years. It had a history of anorexia, for 2 days, and passing green feces. The falcon died overnight. A few days later, it was confirmed that the falcon had died of avian influenza and had tested positive for H₅N₁. The virus might have been introduced from illegally imported falcons from China and Mongolia early in the season. The authorities were updated at a later date. Authorities culled 37 falcons kept in a veterinary centre in Riyadh after tests on 31 revealed 5 of them tested positive to the H₅ strain of the avian flu virus. Daily Al Riyadh in its Mon Feb 6 edition said that 2 among the 5 falcons entered Saudi Arabia from the UAE 6-7 months ago, but the Saudi Government clarified that none came from the UAE and it was not confirmed where they came from^ref. If confirmed, and in the absence of disease in domestic poultry, the infection in falcons could have been the result of contacts (during hunting?) with (migratory?) wild birds. An H₉N₂ avian influenza virus has been present for the past several years in various Middle-Eastern countries, including Saudi Arabia. Though not an HPAI virus strain, losses at times have been considerable. These unofficial but reliable data should be brought to the attention of all those involved in the maintenance, handling and healthcare of falcons and other captive birds in the Middle East and elsewhere. Hopefully, it will help in enhancing the alertness of authorities responsible for control upon international trade in avians, with special attention to captive birds. Earlier H₅N₁ incidents related to such trade have been recorded in Taiwan, Belgium, the UK and probably elsewhere^ref. US Fish & Wildlife Service investigations have shown that there is a long standing and well established illegal global trade in falcons and other raptors and that as long ago as 1984, individual falcons caught from the wild could command prices of USD 10,000 - 50,000 from buyers in Europe and the Middle East^ref. NGOs have estimated that the illicit trade in falcons from Central Asia to the Middle East and Gulf states may involve as many as 14,000 or more birds annually and say that individual falcons of the most sought-after species can bring prices > USD 500,000. News media reports from October 2004 said that Russian police had intercepted and confiscated a consignment of 127 Saker falcons worth an estimated USD 4.5 million from a commercial aircraft at a Russian military air base in Kyrgyzstan^ref. This incident remember an earlier documented incident involving H₅N₁-infected eagles smuggled from Thailand to Belgium. There's a lot of smuggling of sakers falcons from Central Asia to the Middle East; and what are they likely to be fed on? Who'd be likely to be in the Erhel Lake region, Mongolia? People after Sakers for the Middle East. I seem to recall that the H₅N₁-infected Mountain Hawk-eagles smuggled from Thailand to Belgium were believed to have been fed infected chicken just before the flight. So perhaps this is how the Erhel Lake, Mongolia outbreak came about.
• EAU : the Environment Agency Abu Dhabi (EAD) with the collaboration of other organisations has recorded 63,338 wild birds during recent surveys as part of the National Bird Monitoring Plan for Avian Influenza in the country. Only one dead bird, a female mallard, was collected from Khor Al Jazeera in Ras Al Khaimah and it tested negative for avian influenza^ref. Birds on Sir Bani Yas, Abu Al Abbyadh and other islands and on the emirate's shorelines were caged on Feb 8, 2006 to prevent them mingling with migratory birds who might be infected with AI^ref
• Lebanon : dozens of migrating storks and quails have died mysteriously over Oct 26-28 in Ras al-Ain^ref and Qleileh along the Tyrian coast^ref.
• Azerbaijan^{ref1, ref2, ref3, ref4} (8.4 million inhabitants; lies on the shore of the Caspian Sea in the Caucasus, bordering the Russian Federation, Georgia, Armenia, Turkey, and Iran. As common in the whole subregion, migratory birds fly through Azerbaijan twice each year, from Siberia to Africa in the autumn (August-December) and back in the spring (February-May)) : mass death of migratory birds occurred in Nakhichevan (also spelled Naxcivan or Nakhchevan) Autonomous Republic of Azerbaijan on Oct 24. About 200 dead ducks were found near Araz reservoir and buried : blood analysis was taken from dead ducks but deaths remain undiagnosed. Nakhicheva forms an exclave separated from the rest of the country by Armenia to the north and east and bordering on Iran and Turkey to the south and west^ref. Araz (the Azarbaijani name) is a river rising in Anatolia in Turkey, flowing along the Turkey-Armenia border, then along the Azerbaijan-Iran border, entering Azerbaijan, and falling into Kura river as a right tributary. Total length is about 600 miles. Iran announced in October 2005 that their dead ducks tested negative for avian flu. But die-offs continued in Azerbaijan until February 2006, and under foreign pressure Azeri officials finally sent samples to the flu reference lab in Weybridge, UK. On Jan 6, 2006, 200 birds died in 2 villages in the Massaly region and tested negative in Baku on Sat 7 Jan 2006. The Massaly region is near Azerbaijan's border with Iran and about 500 km (300 miles) southeast of the remote Turkish district where a bird flu outbreak in humans has killed 3 children. The Massaly region is situated in the southeastern part of Azerbaijan's main territory, which has no direct borders with Turkey^ref. On Feb 10, 2006 it was announced that the results from tests on dead wild birds found floating on the Caspian Sea in Turkan, Baladzhary, and Karadag villages, near the Absheron peninsula, which includes the capital Baku, and off the southern Massaly region, near the border with Iran, on 29 Jan showed the presence of the H₅N₁ bird flu virus^{ref1, ref2}. Absheron district, Dzhejranbatanskiy Territory has been under quarantine. A few days later, 15 more wild birds were found dead in the Ceyranbatan reservoir, which provides most of the water for the capital Baku. > 1000 swans and 100 crows were found dead at the sea coast near the northern Khachmas (Khachmaz), Samukh, Fizuli, and Devechi Districts. Dozens of carcasses of wild swans, ducks, pelicans and cormorants littered the beaches; dead wild and domestic birds have been found in Masalli, Bardeh, Ganjeh, Douche and around Baku. The finding of a dead seal has also been reported. The first case of mass deaths among birds was registered in October 2005 in the Nakhichivan Region, bordering Turkey. Some domestic poultry were found dead in Masalli district at the end of December 2005 and beginning of January 2006. Kilyazin farm has been put under quarantine after avian flu virus was found in samples taken on 22 Feb 2006^ref. 2 residents of Pirallakhi who are sisters were been taken to a hospital with isolation facilities on 12 Feb 2006. Although they had high temperatures when they were admitted, they were later discharged at the request of relatives, and both are in a satisfactory state of health. On 14 Feb 2006, Russia imposed restrictions on imports of live birds, incubatory eggs, poultry flesh and other products from Azerbaijan. Since 22 Feb 2006 260,000 birds died at a poultry farm in Gilyazi (Ghiljazi) village, Khyzy district, some 60 km north of the capital Baku, and 36,000 in Samedabad village, Biljasuvar district^ref : on 2 Mar 2006 the presence of the virus was detected by laboratory tests^ref. On 24 Feb 2006, the country announced detection of infection in poultry at farms in Khyzy (in the north-eastern part of the country) and Bilasuvar (near Salyan). Some 300 000 birds were culled as a result^{ref1, ref2}. On Mar 20 WHO experts fear 14 more people in Azerbaijan are infected with the H₅N₁ strain of avian influenza : Interfax news agency reported Monday that the WHO officials reported their suspicions following a visit to Salyansky district, 90 miles (150 km) south of the capital^ref. As of Tue 11 Mar 2006, samples from 11 patients under investigation in Azerbaijan for possible H₅N₁ infection have now been tested at a WHO collaborating laboratory in the United Kingdom. Positive H₅N₁ results were obtained for 7 of these patients (marked in red) : 4 cases were fatal^ref.
• 7 of the cases occurred in Salyan Rayon in the south-eastern part of the country
• 6 cases resided in the small Daikyand (Daikend / Daikvend) settlement of around 800 homes.
• a 17-year-old girl from Sarvan settlement (Khatira Abbasova, daughter of Ferhad Abbasov) was admitted to hospital on 20 Feb^ref and died on 23 Feb 2006 (tested positive on 14 Mar at NAMRU-3). She was reported to have suffered for > 1 year from respiratory symptoms associated with a neoplastic condition. Her death is now thought to have been caused by this pre-existing disease. As a precaution, samples were taken and sent for H₅N₁ testing at a WHO collaborating laboratory in the United Kingdom, where they tested positive^ref
• her first cousin, a 20-year-old woman (Nabat Askerov), died on 2 or 3 Mar and they tested positive^ref
• the 16-year-old brother (Shakhmar Askerov^ref = Shahriyar Asgarov^ref) of this woman helped to gather carcasses of dead swans, and was admitted at hospital on Mar 4 with pharyngodynia cough and fever, developed bilateral pneumoina on Mar 3^ref and died at the Pulmonologi Research Institute^ref on 10 Mar^ref, and tested positive^ref
• 2-year old Sahsenem Ibrahimova from Dayikend village in the Salyan rayon (district) is hospitalized but in good health^{ref1, ref2}
• Sarvan village :
• a 16 or 17-year-old girl (Gyunel Gasymova^ref), a close friend of the family, died on Wed 8 Mar night. All 4 of these cases lived together or near each other. The source of their infection is presently under investigation; she tested positive^ref
• 9-year-old Amrah Ismailov, a resident Sarvan village in Salina region, is considered to be good^{ref1, ref2}
• a 10-year-old boy, who has recovered and was discharged, tested positive^ref
• a 15-year-old girl (Ulkar Asgarova), who is hospitalized in critical condition but is responding to treatment in Baku's hospital No.2^ref, tested positive^ref. She has also fully recovered and been discharged from hospital^ref
• her 17-year old cousin developed symptoms on 11 Mar 2006. She was seriously ill with bilateral pneumonia but has since fully recovered and been discharged from hospital. Early in her course of illness, a diagnosis of H₅N₁ infection was presumed based on her clinical symptoms and preliminary laboratory results, and she was treated accordingly. H₅N₁ was confirmed in the UK on Apr 11^ref
• 2 other sisters from the Askerov family, a 15-year-old and a 16-year-old, were hospitalized with bird flu symptoms on Mar 30, 2006^ref : the 16-year old girl tested positive for H₅ and was treated in Child Clinic Hospital^{ref1, ref2, ref3}. Also the other 15-years old sister had tested positive for H₅N₁^ref.
• 2 additional patients, from Salyan and the adjacent rayon of Neftchela, have been hospitalized with symptoms of bilateral pneumonia. Testing of these patients is presently under way
• a 16-years old boy (Ashurov Alakharia) was also taken to Baku hospital on bird flu suspicion and his condition is reported to be satisfactory. He might be discharged from the hospital in a day or two^ref
• Kyurdamir province :
• Manafov Elsever Panah (20) - reported hosp in Baku on Mar 07
• Sabirabad (Sabriabad)^ref sakini :
• 19-year old Nurane Xelilova
• Nerimanov (Narimanov) district^ref of Baku
• 13-year old Meleyke Rzazade^ref from Saatly rayon is in serious conditions^{ref1, ref2}
• unknown provinces :
• a 35-year-old Ziyafet Mukhtarova from Salyan is good^ref
• 5 year old - reported hosp in Baku on Mar 05
• Ahmadov Yashar Bahlul (14M) - reported hosp in Baku on March 07
• Ahmadova Kamila Bahlul (17F) - reported hosp in Baku on March 07
• Mammadova Agaselim Arif (13) - reported hosp in Baku on March 07
A field investigation in Salyan, jointly conducted by WHO and the Azeri Ministry of Health, found some evidence that carcasses of numerous swans, dead for some weeks but not buried, may have been collected by residents as a source of feathers. In this community, the defeathering of birds is a task usually undertaken by adolescent girls and young women, which explains the predominance of female cases. The WHO team is today investigating whether this practice may have been the source of infection in Daikyand, where the majority of cases have occurred in females between the ages of 15 and 20 years. Interviews with surviving family members have failed to uncover a history of direct exposure to dead or diseased poultry for several of the cases^ref. The Salyan Rayon is located near wetlands frequented by migratory birds. Close contact with and de-feathering of infected wild swans was considered to be the most plausible source of exposure to influenza A/H₅N₁ virus in the Salyan cluster, although difficulties in eliciting information were encountered during the investigation, because of the illegality of some of the activities that might have led to the exposures (hunting and trading in wild birds and their products). These cases constitute the first outbreak worldwide where wild birds were the most likely source of influenza A/H₅N₁ virus infection in humans^ref.
• central-western rayon of Tarter : a 21-year-old woman from Bayim-Sarov developed symptoms on Feb 28, was initially diagnosed as reactivation of tuberculosis and A/H₅N₁ virus infection was only considered when a second (probable) patient became ill on 4 Mar 2006. The first patient died on 9 Mar 2006 and tested positive^ref on 14 Mar at NAMRU-3
The majority of patients developed respiratory symptoms, with the exception of one patient where meningeal signs were predominant, as already observed in Vietnam. Severe hypoxia, caused by the prolonged course of viral pneumonia, appeared to be under-recognised and treated late in children. The early establishment of oxygen saturation monitoring and provision of continuous oxygen therapy is therefore crucial to prevent decompensation and multi-organ failure already observed in cases of influenza A/H₅N₁ infection elsewhere.
By decision of the Veterinary Administration, quarantine was lifted on 8 Apr 2006 in the affected area^ref.
Supplies of oseltamivirare available in Azerbaijan, but the quantity is limited. To date, all patients under investigation have received treatment with this drug. All fell ill after contact with sick birds and were not thought to have infected each other^ref. Missing a neighbour's funeral is considered deeply shameful in rural Azerbaijan, where traditional Muslim values hold strong, but no one went to the funerals of those girls. "Last week one of my acquaintances was ill and it was bird flu, although the doctors said it wasn't," said Haydar, a 71-year-old man from Salyan. "I am sure there are a lot of people sick with bird flu but the authorities are hiding it"^ref. On Mar 15, 2006 a dead stray dog tested positive for type A bird flu^ref. Public health officials believe some of the victims fell ill when they plucked the feathers from wild swans infected with the H₅N₁ strain of the virus. The feathers are used in pillows. As wild birds fly away from Azerbaijan's territory, the danger of the virus spreading is gradually falling. There have been isolated cases of bird flu among domestic poultry. One village, in the Agdam region, remains under quarantine. Azerbaijan's Union of Poultry Farmers said on Tuesday sales of chicken meat and eggs had fallen by 50-6% since February when the first cases of the virus were identified in birds, making consumers nervous. About 2,500 tonnes of unsold meat is being stored in member companies' warehouses^ref. On Apr 5, 2006, Azerbaijan sent blood samples from 43 people with cold-like symptoms (not all hospitalized) to a British laboratory to test for the H₅N₁ strain of avian influenza. Public health officials, citing local test results, said last week a 16-year-old girl had tested positive for bird flu. She is in hospital and is responding to treatment, officials said. Her blood sample was among the 43 sent to Britain. She was the 1st case of human bird flu infection in Azerbaijan since the 1st week in March 2006^ref.
• Armenia : a crow, a sparrow and an eagle were found dead in Armenia's southernmost region of Syunik on Feb 15^ref, but no strain of the deadly H₅N₁ bird flu virus was found in them after the dead birds were examined at a laboratory in Yerevan^ref
• Georgia : 385 dead hens tested negative on 18 Jan 2006. On Feb 2 2006 > 10 dead wild ducks were discovered by fishermen in Batumi port area. Batumi is the capital of Ajariya, in the southwestern part of Georgia^ref. Some dead ducks were also discovered on the beach near the port. Ajariya borders Turkey, where numerous cases of avian influenza have recently been recorded^ref. Dead wild swans found in the village of Adliya (Adzhara ?), in the Black Sea coastal region of Adjara^ref, a semi-autonomous region not far from the Turkish city of Trabzon, tested positive for H₅N₁ on Thu Feb 23^{ref1, ref2}. Tamta Kukhelava, 12-years old with asthma^ref of the Tbilisi 50th secondary school died of bilateral pneumonia on Wed Mar 8, 2006 ; Diana (Iana ?) Beridze, 7-years old from the same school died of pneumonia in Iashvili children’s hospital on Fri Mar 10 night^ref. By the end of Friday doctors had hospitalized several children from School 50 who had fever and other symptoms, paying special attention to those students who were in regular contact with the 2 girls, including 7-year-old Tengiz Peranidze, who sat at the same desk with Diana Beridze, who developed fever^ref. Lives of 4 other students of the above-mentioned school and 1 of the parents of the school-child were not endangered in any way; 1 student has already been discharged and others might be discharged on Sun Mar 12, but on that same day 5 new patients were admitted with fever to the Tbilisi Hospital for Infectious Diseases, including a kid from the school and his/her mother, and neighbors of the girl, who died a few days ago in Okrokana. About 200 people arrived at Infection Center for recent days, having acute respiratory infection^ref. The doctors describe their condition as satisfactory though some of them are coughing heavily and have a temperature. The patients are staying a ward separate from other patients. Despite officials' statements none of the teachers and only 2 of the school's 824 students showed up for classes on Monday : the 2 students were the children of the school's director Nino Gogsadze who spent much of the weekend calling parents and teachers to reassure them that the school had been cleaned^ref. The deaths were not caused by avian influenza, according to both the Georgian government and the World Health Organization, which has reviewed the laboratory results of biological samples taken from the 2 girls^ref, but nascent reports said that their death was a result of alleged “A” type of virus. The patients were given oseltamivir for prevention of possible outbreak of bird flu either. The tests showed they had died after pneumonia and staphylococcus, respectively^ref. The mobile group of the Ajarian Health Ministry arrived in Diakonidze village, in Khulo District, Ajara, after the symptoms of the acute respiratory disease were detected in 27 adolescents : a 4-year-old child was moved to Khulo hospital with 41°C temperature^{ref1, ref2}. This area is next to the Khelvachauri District of Ajaria (/Adjaria/Adjara/Ajara), which has been under a Parliament-ordained bird flu-induced state of emergency for the last 14 days. It is also < 30 miles from Batumi, where 200 ducks and other wild birds died three weeks ago^ref. A number of residents in Zugdidi, western Georgia, have been infected with a chicken disease. The market place were the infected had bought the chickens has been sealed by the finance police^ref. 3 soldiers were taken to Davit Aghmashenebeli Church Hospital of Kutaisi, to the department of intensive therapy on March 17. They are the soldiers of the subdivision under the Defence Ministry, dislocated in Kutaisi, Imereti region, western Georgia. The diagnosis of Rodani Chachanidze, Giorgi Gamezardashvili and Nikoloz Narchemashvili is the acute respiratory infection with pneumonia. They were brought to the stationary hospital with the nasal bleeding. They are being delivered the treatment at the reanimation department currently. InterpressNews was informed that another 19 soldiers are ill with the similar symptoms but they have no acute forms of the disease like the their abovementioned colleagues^ref. The girl's 10-year-old brother also fell ill on 19 Feb and died on 28 Feb 2006. As his symptoms were compatible with a clinical diagnosis of dengue haemorrhagic fever, no testing for H₅N₁ was carried out. It will therefore never be known whether he may have died following co-infection with dengue and H₅N₁ avian influenza^ref. 10 wild swans (9 dead and one still alive) were found at a small lake located far from the village of Ajaria^ref. In 5 villages in a 5-km zone around the outbreak, stamping out has been applied to 1700 domestic poultry. Measures relating to quarantine and the emergency situation were lifted 15 days after the last case, which was 23 Feb 2006
• Turkey^ref (HPAI had never been reported before; 72 million population) : since 1 Oct 2005 1,700 turkeys out of 1,800 died from AI in a backyard flock kept in a sparsely populated area (military zone) between Kiziksa (Kýzýksa) and Salur villages, district of Manyas, Balikesir province, which is near the Aegean and Marmara Seas, in western Turkey^{ref1, ref2}. The affected area is near to a natural park called Bird Paradise. Belikesir is situated in the southwestern, Asian part of Turkey's northwestern Marmara region (which has also a European part)^{ref1, ref2}. On Thu Oct 6 officials went to the village and destroyed the 100 turkeys at the farm that were still alive and buried them, then disinfected the area. Samples from the infected animals are being tested at a laboratory in the western city of Bornova in the province of Izmir, neighboring the province of Balikesir. On Oct 6 the Bornova Veterinary Control and Research Institute confirmed that the birds in Turkey died of the H₅ type of bird flu (rapid test for influenza A positive; ELISA negative; on 7 Oct 2005: inoculation into embryonated chicken eggs positive; haemagglutination inhibition test positive for virus subtype H₅). A low-pathogenic H₉N₂ avian influenza A virus is known to be present during recent years in various Middle-Eastern countries, moderately affecting chickens and turkeys. Based on the initial test results from the national reference laboratory (Bornova Veterinary Control and Research Institute), the local Veterinary Service quarantined the affected holding on 6 Oct 2005. On Sat Oct 8 officials ordered all winged animals (a further 2,500 Turkey’s and chickens) and street dogs in the village where it was detected destroyed as a precaution against the disease spreading : in the protection zone, 2684 backyard turkeys kept outdoors and 2200 backyard poultry and other domestic birds (chickens, ducks, pigeons, etc.) were killed and destroyed on 10 Oct 2005, and their owners compensated. It was decided to cull immediately the 100 remaining live (and mainly sick) birds. All carcasses were buried that same day with lime in 2 pits within the grounds of the farm. In addition, the local Crisis Centre ordered the culling of:- the 2684 free-range turkeys located about 1 km from the outbreak (direct contact); - backyard poultry in the protection zone (within a 3-km radius). All culling was performed by gassing with carbon dioxide in bins. It started on 8 Oct 2005 and was concluded on 16 Oct 2005. They were collected by the staff of the local Crisis Centre and killed and buried in 5 pits next to the waste site on the outskirts of the village. A total of 10 147 backyard poultry (backyard turkeys, pigeons and geese) were culled. All poultry were in good condition and no clinical problems were detected during the culling. In the surveillance zone, a surveillance programme was put into place for all poultry farms. All commercial and backyard flocks are clinically controlled every 2 days. Hunting of wild birds is forbidden throughout the country. The protection zone contains 7 farms, 2 of which had broiler poultry (a total of 15,907 birds), which were slaughtered and their carcasses stored. The slaughtering was carried out under official veterinary supervision in pre-determined slaughterhouses. The remaining 5 farms did not house poultry. As many as 16,000 animals could be culled as a result of the outbreak in the Kiziksa district, set to remain under quarantine for 21 days. The farmer whose birds carried the disease said he had not been checked by doctors yet and was scared to go near his wife and children. The flu was likely carried by birds migrating from the Ural Mountains, which divide Europe and Asia, across Turkey and into Africa. Officials were also checking some 550 000 birds in farms within a 7 km (4.4 mile) radius surveillance zone outside the quarantined area. On Oct 13 the VLA laboratory in Weybridge, Surrey, UK confirmed H₅N₁, indicating a direct relationship with viruses recently found in Russia, Mongolia, and China. The European Commission banned live bird imports from Turkey on Mon Oct 10 after the bird flu outbreak there, and took a similar measure today against Romania. 9 healthy people from 2 families in the western town of Turgutlu were under medical observation after reports of 40 pigeons in their neighbourhood died in mysterious circumstances in 15 days : samples were sent for testing in Izmir, western Turkey, which showed the cause of death was not AI. All 9 are from Manisa, which is close to Kiziksa : on Oct 16 the 9 were sent to home from hospital after their blood tests showed that they were not infected. The state Anatolian news agency reported on Oct 15 that nearly 1000 chickens had died in the east, near the Iranian border, after being transported from the west of the country. It said samples had been sent for tests for possible bird flu, but did not say where exactly the birds had been moved from. Officials there said on 9 Dec 2005 that they had eradicated the avian flu virus in that region after testing thousands of samples and culling 10,000 birds.

Since Dec 15, 2005 AI due to virus subtype H₅ (confirmed on Dec 26) was reported in 4 backyard flocks (1559 birds) in the village of Kopruler, Aralik, Igdir province, in eastern Turkey, one of the main routes of migratory birds passing through Anatolia. The outbreak is located 7 km from Armenia, 15 km from Iran, and 40 km from the Nakhichevan Autonomous Republic, Azerbaijan : 1200 birds died and the remaining 359 were culled. Igdir is a remote rural area where farming and animal husbandry are the main means of livelihood. But poultry are mostly raised by people for their own consumption^ref.
• 4 children, aged between 11 and 15 (Fatma (15), Ali Hasan (7), Hulya (11), and Muhammed (Mehmet) Ali (14-yo) Kocyigit) and from the same family (mother Marifet and father 38-year-old unemployed Zeki Kocyigit). Their family raised chickens and they handled them on a regular basis. Fatma killed a dead chicken, Mehmet and Hulya plucked its feathers, Marifet cooked and they all ate it, but only the children became ill. Hasan Ali kicked the chicken's severed head like a football^ref. The children most likely contracted bird flu while playing with dead chickens, explaining why their parents were not affected. The children reportedly had tossed the severed chicken heads around like balls inside their house. The Kocyigit family took their fowl inside the house when temperatures fell at night during winter^ref. The house has no running water and they rely on a spring. A partitioned section of the backyard serves as a toilet. Their 8 chickens had lived in a small coop next to the house, in the Turkish tradition.2 days later (Dec 31) Mehmet developed the first symptoms, but the family did not even have the two lira ($1.30) to take him to hospital. Marifet thought initially the boy had caught cold because he lacked suitable shoes and clothes for the severe wintry weather. Finally Zeki found the coins to take Mehmet to the dispensary : the doctor looked at Mehmet and accused him of feigning illness so he could skip school. He prescribed some syrup and sent they off^ref. All the children then developed nausea, coughing, oral bleeding and a high fever. On Sat 31 Dec 2005, the 4 children were admitted to 100th Yil University Medical Faculty Research Hospital in Van province after exhibiting "flu" symptoms and failing to respond to antibiotics. It was suspected that he and the other members of his family may have contracted the virus after eating the meat of a sick chicken. Mehmet died on Sun Jan 1 evening : he was buried on Jan 5 by an imam wearing a mask in a deep grave covered with lime as a precaution. Nasal swabs from all 5 initially tested negative for influenza virus at Ankara Hifzissiha Institute on Jan 2. The authorities repeated the test in 2 separate laboratories after an autopsy on the boy and on Jan 4, 2006, Mehmet and Fatma, who was seriously ill in hospital, were confirmed as H₅N₁. Fatma died on Jan 5 at around 6.30am (1530 AEDT) despite treatment with oseltamivir^ref. In her final days, Fatma told another patient she was scared of dying in hospital because her mother had died there of kidney failure 8 years ago. Financial problems had delayed the mother's treatment - a plight which came back to haunt the family. The 11-yo sister (Hulya Kocygit) died on Jan 6 : despite initial nasal swabs were negative, postmortem lung samples tested positive on Jan 12. Their 6-year-old brother Ali Hasan was discharged on Jan 9 : though ill, he was found not to have the deadly virus. As they look to the future and the task of bringing him up, his parents are at least spared the money worries faced by their neighbours in Dogubayazit. Kocyigit met the prime minister at his parliament offices on Tuesday and took up a state offer to settle his family in Ankara, where he will be given a job and his son an education. Fatma's tearful father Mehmet Emin took her to hospital 10 days after they ate the duck and 5 days after she fell ill : "They made me sign a promissory note for my wife when I brought her to hospital. I thought of that note when my daughter fell ill ... so I didn't want to take her to hospital". Zeki Kocyigit, father of 3 of the dead, has not worked since his shop closed several years ago. He made ends meet by occasionally smuggling cigarettes from Iran while his dead son Mehmet Ali made candyfloss to sell to school friends. The family lived in a four-roomed shack without running water on the outskirts of Dogubayazit. Only a path led to the house until the health minister visited this month and workmen with mechanical diggers carved out a road for his car. As for Fatma Ozcan, she never got the chance to go to school. She spent her short life caring for her family until her death. People don't believe they won't be charged for the bird flu treatment because they fear they have to sign promissory notes^ref
• on Sun 1 Jan 2006, a 35-year-old woman and a 5-year-old child were also sent to the hospital  in the province of Van, near the Iranian border, < 100 km (60 miles) south of Aralik. They recovered.
All 6 patients come from the district of Dogubayazit in the far eastern province of Agri, a remote rural area near Turkey's border with Armenia, 40 miles (60 km) from Aralik. Veterinary Services found 3 dead poultry in a rubbish basket near houses in Dogubeyazit. Entrance and exit of live poultry and poultry products to and from Agri was forbidden on 26 Dec 2005 due to the AI outbreak in Igdir. As of 1 Jan 2006, any movement of live poultry and poultry products into and out of Dogubeyazit was forbidden. A total of 12 teams were established for checking all poultry for suspicion of infection. Some staff members who work another district, deployed in Agri between 31 Dec 2005 and 5 Jan 2006, found a total of 83 dead animals, some in rubbish baskets -- and destroyed them. In the same period, 3169 live animals were killed; all carcasses were buried with lime in pits in the ground. Very intensive clinical surveillance has been continuing. Bio-security measures have been increased. Public awareness is being raised and training is being performed^ref :
• 11 other people from the family (2) and the area (6) are also seriously ill with the same symptoms in Van for suspected avian influenza : 4 more were reportedly sent to hospital in another city, Erzurum, when Van ran out of emergency ventilating equipment. Further, on Jan 5 6 patients from Igdir province were sent to hospital^ref.
• 5 other people (including a 13-year-old boy from Sanliurfa, near the border with Syria^ref) were admitted to a hospital in Diyabarkir, about 250 miles away, for possible bird flu. A poultry trader, his wife and 2 children, from the southeastern city Sanliurfa bordering Syria, felt sick after cutting and eating a sick chicken on Fri 6 Jan 2006, and on Jan 7, 2006 were  transferred to Harran University Hospital^ref. Rumors that a man had died from the disease near Syria's northern border with Turkey were denied by Syrian officials (death attributed to pulmonary illness)^ref
• the 2 year old-Davut Polat was treated at Erzurum Ataturk University (AU) Yakutiye Research Hospital : no bird flu virus was detected in the child during his initial examination.
• reports of fresh cases emerged from Dogubayazit. Mehmet Nuri Elnazik told CNN Turk his 3-year-old child was gravely ill^ref. 23 people were treated at Van for suspected bird flu on Jan 7 : 15 of them are in bed, 1 in critical condition. 8 are able to move about. Most of the patients are children. The Anatolia news agency later said 26 people were receiving treatment at Van hospital : 18 others had been discharged after being cleared of having the disease^ref. On Jan 7 the number of suspected cases escalated to 32 (most children from Dogubayazit)
• on Jan 7, WHO confirmed that a 5-year-old boy (Yusuf Tunc^ref ?) and an 8-year-old girl (Sumeyya (Sumeyye ?) Mamuk) from Dogubayazit, both hospitalized, tested positive for H₅N₁^ref. The children's condition has improved, and they are currently well. The 8-year-old girl hospitalized in Van with what Turkish labs showed was H₅N₁ apparently contracted the virus by hugging and kissing dead chickens : she was released from hospital on Thu Jan 12 after being treated with oseltamivir^ref. The 14-strong Kurdish family live in a cramped 4-roomed, 1-storey house with no running water and little heating for the cold winter -- like many others in this poor region
• her 18-year-old cousin was discharged on Sat Jan 14 after treatment with oseltamivir^{ref1, ref2}
• on Jan 8, a family of 7 people, including 5 children, from the eastern town of Ardahan, was sent to hospital in Istanbul on Fri Jan 7
• on Sun 8 Jan 2006, out of 28 samples diagnosed, 5 tested positive for H₅N₁
• 5 people in Ankara (some 1000 km from Dogubayazit, about 400 km (250 miles) east of Istanbul)^ref: Ankara is a relatively well-off area, where humans and animals do not live under one roof^ref.
• 2 boys, aged 2 (Iskender) and 5 (Muharrem Canak), were believed to have touched gloves used by their father to carry to the authorities 2 wild ducks dead from bird flu that the man found earlier in the week outside their hometown of Beypazari, 62 miles north west of Ankara. Their parents tested negative. The boys developed mild sympoms despite testing positive for the virus. The cases (aged 5 and 6 ??) are the first documented at such an early stage, and authorities expect the boys to develop symptoms^ref. They seem to be the 1st reported human cases following contact with wild birds and were  discharged on Jan 19
• 2 young brothers, ages 4 and 5, who have tested positivefor the A(H₅N₁) avian virus but shown no symptoms at all of the disease were being closely watched at Kecioren Hospital here on Tue 10 Jan 2006
• a 65-year-old man from an Ankara suburb, was also in good condition despite contracting the virus after coming in close contact with chicken he bred
The 5 cases in Ankara hospitals are different from those elsewhere in Asia. 4 of the 5 display only mild symptoms, or no symptoms at all. Also, although all 5 have had some recent contact with birds, they are people who live on the fringes of a major city, not farmers or people who keep birds in their backyards. The boys are all being treated with antiviral medicines.
• a 9-year-old girl and his 3-year-old brother, cousins of the 16-year-old girl dead on Jan 15, from Dogubeyazit are in hospital in Van^ref. They recovered and were discharged late Mon 22 Jan 2006^ref
• a 5-year old boy from Cayyaka village, Corum province, was admitted to hospital with suspected bird flu in Cankiri province in central Turkey^ref
• on Mon 9 Jan 2006 5 cases in the Black Sea provinces of :
• Kastamonu (2) (a town about 250 km north of Ankara)
• Corum (1) (a town about 250 km northeast of Ankara)
• Samsun (1) : 12-years old Osman was treated with oseltamivir, recovered and discharged on Sat Jan 14^{ref1, ref2}
• and the eastern province of Van (1)^ref
• a new case in the southeastern Mush Province^ref
• 2 children in the mainly Kurdish provinces of ... :
• Siirt (adjacent to Van in the eastern part of the country) : 6-year old
• Sanliurfa (near the southern border with Syria) : 4 year old Selami Bas, who had been in the hostpital for 12 days fighting the effects of bird flu, was released on Jan 18, 2006^ref
... had a story of contact with chickens, and were confirmed on Jan 12 and are in stable conditions in hospital^ref. They have been treated in the hospital with oseltamivir as the other cases are^{ref1, ref2}. In Sanliurfa Province, outbreaks in backyard poultry are now thought to date back to late November 2005.
• a 37-year-old woman (Gulten Yesilirmak) and 3 of her children were hospitalized in the central province of Sivas on Sun Jan 8 night suffering from flu-like symptoms. While only the mother tested positive (the only one among 61 samples tested) for bird flu her 3 children were still kept in a state hospital in Sivas. She is a mother of 2 (?) who fell ill after coming into contact with sick chickens : other 7 patients are being tested. Although no poultry outbreaks have been officially reported in this province, it is located near areas with confirmed outbreaks in birds^ref. A number of chickens the family owned had died and that she had thrown them in the rubbish using her bare hands^ref
• 4 people were taken to hospital on Jan 10 with suspected bird flu in the town of Aydin near the Aegean coast -- one of Turkey's most important tourism centres. On Tue Jan 10, 2006, mass wild and domestic fowl deaths near the popular Kusadasi resort (which literally translates as "bird island") which faces the Greek island of Samos on Turkey's Aegean Sea coast, 580 km from Istanbul and 1,650 km from Dogubeyazit ^ref. 3 of the cases were in the regional capital of Aydin while one patient (3-years old Umut Sagbas) had been playing with a sick chicken at his home in Kusadasi before falling ill^ref
• abroad :
• on Wed Jan 11 night a Turkish citizen was admitted to a hospital in Bucharest with bird flu-like symptoms^ref
• on Sun Jan 15 Belgium doctors ruled out bird flu in the journalist with the Russian Vesti television channel who had been hospitalized at Saint Peter's Hospital in Brussels after falling sick upon returning from infected areas in Turkey : he was diagnosed with seasonal H₃.
• a 4-year-old girl died earlier on Fri Jan 13, 2006 at Diyarbakir hospital ^ref
• a 2.5-year-old girl (Sahibe Yetistiren) from Cinar, near Diyarbakir, with no history of contact with birds, fell ill on 5 Jan, deteriorated despite antibiotic treatment at home and was brought to Diyarbakir hospital late on Thu 12 Jan 2006, where died on Jan 13 with severe right bacterial pneumonia^ref. One should be reminded here that a secondary bacteria pneumonia can be a complication of an influenza infection and hence the caution on the part of the health sector in Turkey. The absence of exposure to sick birds further reduces the likelihood of avian influenza in the above "suspected" case.
• 2 siblings from Dogubayazit contact with fowl and apparently ate a chicken that had been shown signs of illness, developed symptoms on Jan 4 and were admitted to Van Yuzuncu Yil hospital hospital on Jan 11 where they were treated with oseltamivir^{ref1, ref2, ref3} : ducks began dying in the family's household flock on 1 Jan 2006. No other family members have developed signs of illness.
• a 14-year-old girl (Fatma Ozcan) on 1 Jan had butchered a dead duck herself, assisted by her brother, cooked them and served to her family : she initially tested negative for H₅N₁ but died on Sun Jan 15 and tested positive on Jan 16
• her 5-year-old brother (Muhammed Ozcan) tested positive for H₅N₁ AI virus on Jan 15. The boy has a fever, but the infection in his lung is light; it'sattached to respiratory equipment
• a 5-year-old boy from the town of Gebze, around 100 km (60 miles) south of Istanbul, had contact with chickens kept in the yard surrounding his house, developed high fever, was brought 1st to a medical center in Gebze for tests before being transferred to the hospital in Istanbul on Sat 14 Jan 2006 with suspected AI^ref. He tested negative and was discharged on Jan 16^ref
• 2 children, 11 and 13 years-old, with bird flu-like symptoms have been hospitalised on Sat Jan 14 in Istanbul after coming into contact with chickens in Gebze town. The children were being treated in hospital, but it was not immediately clear whether they had been tested for bird flu^ref
• an 11-year-old girl (Sevgi Acar) from Bulanik town in Mus province was initially diagnosed as a pneumonia patient and sent to Karacoban State Hospital in eastern Erzurum province, but died at around 5:00 a.m. on Jan 18, 2006 on the way to transfer to the Aziziye Research Hospital in the eastern city of Erzurum^{ref1, ref2}. She had no respiratory complaints and no direct contact with any poultry prior to her death^ref
• 3 people, including a child, have been urgently admitted into the Mugla town hospital after they had been in contact with dead hens that had tested positive for the bird flu virus^ref
• a 5-person family (3 adults (aged 55, 38 and 27) and 2 children) from Konya province in Turkey has been admitted into the Konya town hospital on account of feeling sick after eating the meat of one of their own chickens^ref
• a 4 year old boy from the district of Dogubayazit in Agri Province in the eastern part of the country tested positive on Jan 18, 2006. An outbreak in poultry began in the district in December 2005. The child developed symptoms on 5 Jan 2006 and was admitted to hospital on 13 Jan 2006. He is being treated at a hospital in Erzurum province Aziziye Research Hospital, is in a stable condition and can eat and drink^ref

 
• Yozgat: measures were increased over the deaths of birds in 4 villages of the Akdagmadeni district. Almost 2,500 birds were killed. 3 were hospitalized at the Hospital of Sivas Cumhuriyet University as a precaution against possible bird flu stroke^ref.
• Esat Bal, 13, transferred from Siverek to Diyarbakir and hospitalized at the Hospital of Dicle University, remains in critical condition and is receiving intensive care^ref.
• Siirt: 5 children from the Baysal family were hospitalized at the Research Hospital of Dicle University on suspicion of bird flu infection. The Baysal family, residents of the Celikli Village of the Baykan District, lost their chickens 4 days ago^ref.
• Agri: 5 were transferred from the districts of Diyadin and Tascay to Erzurum on suspicion of the bird flu infection. The number of animals killed increased to 27,843^ref.
• Erzurum : all the fowls in 3 villages and 10 small districts were killed as part of the quarantine policies applied in the district of Horasan^ref.
• Bitlis : the bird flu strain was detected in the Aydinlar area of the Adilcevaz district. Samples taken from the pigeons that died 2 months ago were sent to Bornova, Izmir. The pigeons were diagnosed with the bird flu strain. No fowls were let either in or out of the city^ref.
• Ankara : after the bird flu was detected in 2 ducks in Nallihan town of Ankara a crisis desk was established. About 10 people who brought the 2 ducks with bird flu to the agriculture headquarters of the town were sent to the hospital for control. No illness was detected in these people^ref.
• Van : reportedly 3,813 poultries were massacred in Caldiran town and 55,000 more poultries will be massacred to prevent the spread of the illness^ref.
• Igdir: 2 children were reported to be sent to Erzurum for bird flu possibility. Quarantine is being applied throughout the boundaries of the city^ref.
• Yalova : no bird flu virus was detected in the 7 member family, 5 of whom were children, in Istanbul Haseki Hospital. Istanbul Health Manager Mehmet Bakar explained the children did not have bird flu virus but regular influenza and they were discharged from the hospital^ref.
From the patients undergoing treatment in Van, 26 were from Dogubeyazit, 4 from nearby Igdir and 3 others were from Van. 23 people were being tested for the disease in Istanbul (14 of them from the same famil) : 12 of 23 tested negative on Jan 10. Human cases have now been reported from 9 of the country’s 81 provinces. The rapid assessment of patients with a possible exposure history is providing a unique opportunity to learn more about the disease in humans. It is also generating data that can be used to assess the efficacy of antiviral drugs, as most people with an exposure history or respiratory symptoms are receiving oseltamivir either prophylactically or very early after the onset of symptoms^ref. On Jan 12 the WHO Collaborating Centre for Reference and Research on influenza at the MRC National Institute for Medical Research in Mill Hill, London, completed genetic and antigenic analyses of viruses recovered from the first 2 fatal human cases in the Turkish outbreak. Information provided to WHO indicates that these viruses are very similar to current avian H₅N₁ viruses isolated from birds in Turkey. They are also closely related to viruses isolated from the large outbreak in migratory birds that occurred at the Qinghai Lake nature reserve in China, beginning in late April 2005. These analyses indicate that the Turkish viruses are sensitive to both classes of antiviral drugs, including oseltamivir and amantadine. WHO and collaborating experts will review the data on amantadine sensitivity. Oseltamivir remains the drug of first choice recommended by WHO. 50% of virus from one of the patients shows a serine to asparagine mutation at position 223, in the sialic acid-binding site of hemagglutinin and is considered to increase the ability of the virus to attach to human cells : this has been seen previously in viruses isolated from a small outbreak in Hong Kong in 2003 (2 cases (a father and son), 1 of which was fatal) and from the 2005 outbreak in Viet Nam (1 case). Research has indicated that the Hong Kong 2003 viruses bind preferentially to human cell receptors more so than to avian cell receptors. Researchers at the Mill Hill laboratory anticipate that the Turkish virus will also have this characteristic. It is unclear whether the mutation occurred in the person or whether it occurred in the chicken. The mutation also has a secondary effect, which may be more worrying. There are 2 subtypes of receptors in the human respiratory tract: a2.3, which occurs mainly in the lower respiratory tract; and a2.6, which occurs mainly in the nose and throat. Human flu viruses typically show a preference for the a2.6 receptors, whereas H₅N₁ strains typically prefer a2.3. This is good news for those worried about bird flu, since human-to-human transmission is thought to be more likely via droplets coughed from the nose and throat than from infections lower down. But the mutation found in the Turkey viruses is also known to be able to increase the affinity for H₅N₁ to the a2.6 receptors. The virus found in Turkey is mostly related to the virus strain that caused an outbreak in migratory waterfowl at Qinghai Lake starting in Apr 2005. The same sample also contained a mutation at position 153 of the haemagglutinin protein : this information was not included in WHO statements, because it is not clear what role this particular change plays. All of the virus isolates sequenced from that outbreak were shown to have the glutamic acid to lysine mutation at position 627 (E627K) in the PB2 gene, which has been associated with increased virulence in mice, and observed in all human influenza virus strains, including the 1918 H₁N₁ virus. This mutation has been seen in other flu sequences from Eurasian poultry over the past year. It was also present in the one person who died during an outbreak of H₇N₇ in the Netherlands in 2003, and in a few people in Viet Nam and Thailand. The polymerase mutation is one of the 10 genetic changes that gave rise to the 1918 pandemic flu virus. Glutamic acid is associated with flu-virus replication in birds, and glycine is in primates^ref
Elsewhere, people say hospitals are overcrowded and doctors do not examine and treat them adequately, sending them home after brief examinations.
Officials said physicians treating the Kocyigit children did not have a supply of oseltamivir. Hospital officials launched a search of pharmacies at the hospital, located in Van province, and finally obtained a supply from a woman who said she had purchased 2 boxes in October 2005, but they were too late to save the infected children, which had been ill for a week. Health Ministry officials said on Jan 6 that 5,120 boxes of the antiviral drug were dispatched to eastern Turkey on Dec. 31. On Jan 7 Van hospital had enough supplies^ref. 5 artificial respiration machines were also sent to the hospital in Van. Roche officials said the Turkish Health Ministry had a stock of 15,000 boxes of Tamiflu on hand. After the deaths this week, the company assembled a rush order of 100,000 more boxes, which arrived on Fri 6 Jan 2006^ref. Turks across the country hunted for the influenza medicine in pharmacies, while in the eastern part of Turkey, even simple gloves and masks were in high demand. Hospitals and clinics in eastern and southeastern parts of the country, where some H₅N₁ bird flu cases were confirmed in fowl, were overwhelmed with people suffering from regular human flu^ref. Unlike the former outbreak in Western Turkey, things are different in eastern Turkey. Education is key to controlling the spread of the virus, but that is hampered by poverty and the inability of many in Dogubayazit, a largely Kurdish town, to speak Turkish. Children living in villages enter hen houses and that increases the death ratio among children as they become infected by the bird flu virus. Presumably adults do not normally enter these hen houses and children are responsible for their maintenance. A prosecutor in the eastern town of Kars had begun an investigation into culling poultry by burning them in pits because causing pain to animals is illegal. The owners will be paid 5 new Turkish lira [3.75 U.S. dollars] per chicken. For the killing of one goose, the amount will be 10, and for the killing of one turkey, 15 liras will be paid in compensation, which is normally sold for 30 lira in the market, and that is why they do not want to give their poultry to officials for culling. The fear of becoming infected with bird flu has initiated some people to destroy large numbers of poultry on their own instead of calling officials. Oblivious killing of animals is posing a high risk of helping the virus to spread.
Authorities identified bird flu in 5 areas and placed them all under quarantine : agriculture officials there have so far culled 1,500 fowl and aimed to kill the remaining 2,000 before burying them in a rubbish tip 10 km outside the town. At least 4 new outbreaks of bird flu in the eastern province of Igdir, where the 2 victims lived, 250 km further west in Erzurum (> 700 poultry culled as a precautionary measure, after 15 chickens died "in suspicious circumstances), and 750 km away in Sanliurfa to the southwest. In Istanbul, the biggest city in Turkey, authorities immediately took 4 pigeons, found dead on late Jan 4 near a mosque, to a lab for bird flu tests and sprayed the area with disinfectants : on Jan 9 initial tests on 2 dead chickens in the Istanbul district of Kucukcekmece indicated they were infected by the bird flu virus^ref. On Jan 6, bird flu was detected in 2 wild ducks near a dam at Nallihan (about 100 km west of the capital Ankara, nearly 1000 km (700 miles) west of infected areas where the 3 children died)^ref : the Nallihan area is characterized by wetlands with an abundance of water birds, such as gulls, herons and ducks^ref. Dead chicken in Karahidir  village in the northwestern province of Bursa, some 1,400 km (870 miles) from the worst-hit areas in the east, tested positive for bird flu on Jan 8 : the province is the most western point in the country where the virus has been detected. Samples from wild pigeons in the eastern provinces of Erzincan and Bitlis also tested positive : the outbreak in Bitlis on Nov 2005 was confirmed on Sat 7 Jan 2006. On Jan 8 dead chickens in 2 villages in northern Zonguldak province on the Black Sea coast, some 1,200 km from Dogubayazit, tested positive : nearly 1500 poultry in 2 villages will be culled^ref. Authorities have culled thousands of fowl in the affected regions, but in the village of Dagdelen, on the outskirts of Dogubayazit -- the hometown of the 3 children who died -- villagers gathered outside an Agriculture Ministry building to complain that no one had come to cull their fowl. In nearby Bozkurt village, local administrator Ahmet Koylu said chickens and dogs were dying but that no one had come to investigate. In the province of Yozgat, about 200km east of here, on Jan 9 the virus was detected in dead fowl in at least one village^ref. The 5 official notifications sent by Turkey so far did not mention disease in wild birds, including pigeons (which might be semi-domesticated); according to the official reports, the species clinically affected on farms were chicken, goose, turkey and ducks; positive laboratory results related to sampled chicken and ducks. In addition, it has been alleged that the disease is also geographically more widespread than was earlier reported. If allegations that the disease has been spreading, at least in Eastern Turkey, for weeks or even months are confirmed -- then the heroic but belated attempts to apply stamping-out policy in domestic birds kept in small numbers (and in many cases within human dwellings), might be almost sisyphean. If the spread is found to be -- fortunately -- still limited, stamping out may have a chance of success only if the compensations to farmers and owners are realistic, and payments timely. The early establishment of the affected territories will allow making decisions on the disease prevention and control policies to be applied. These might differ in the different provinces, according to their epidemiological status; regionalisation or compartmentalisation principles might be referred to. If the disease has taken wide dimensions, vaccination might not be excluded in selected areas/compartments. In the meantime, special attention should be devoted to public education. This is particularly important in the coming week, when many households in Turkey (similarly to other Muslim countries) are expected to consume increased quantities of poultry meat, during the annual Eid-Ul-Adha festivities. Though, as stated by the WHO, the consumption of cooked poultry meat is permitted, those engaged in the slaughtering process are required to take precautionary measures. In countries -- such as Turkey -- where house slaughtering is widely practiced, especially in rural areas, this is a cause for concern. Moscow raised the prospect of economic damage to Turkey's vital tourist industry, warning Russians against traveling to Turkey after the human infections. Iran, which borders the Turkish region worst affected by the outbreak, closed one of its border crossings, forcing many Turks traveling there for this week's major Muslim holiday marking the Feast of the Sacrifice, to return home. On Jan 9, the EC introduced a ban on the import of feathers from 6 neighbor countries of Turkey : Azerbaijan, Armenia, Georgia, Syria, Iran and Iraq. On the same day the Turkish agriculture ministry drafted legislation to ban outdoor poultry breeding.
Some new aspects of the epidemic situation in Turkey compared with those pertaining in East Asia appear to be the following:
• (1) relatively small outbreaks of disease in poultry in at least 5 widely separated places (several hundred kilometres apart);
• (2) larger number of confirmed (3) and suspected human cases in a limited time-frame;
• (3) children apparently at greater risk of infection;
• (4) ineffectiveness of oseltamivir treatment in at least one case; if we compare the 4 dead children to those who survived, we see that they came to the hospital 10 days on average after they began showing symptoms, while the others were hospitalized after 5 days on average
• (5) failure of poultry culling and quarantine of population to contain the outbreak; and
• (6) for the 1st time serious consideration of the possibility of some limited person-to-person transmission (?)
One obvious possibility is that the virus itself has changed so that the species jump from avian to human infection is now easier. But, what if the circumstances in the country (Turkey) are different:  1st, perhaps there is a greater coverage of the rural population with the formal health sector, so that when illness occurs, the population automatically seeks medical care -- hence, more cases are coming to the attention of the health sector than do in the Southeast Asian countries (a component of "seek and ye shall find").  2nd, perhaps the formal health sector in Turkey has just implemented an avian influenza preparedness plan so the clinicians are very sensitized to report cases of respiratory illness and send appropriate specimens for testing (another component of "seek and ye shall find").  3rd, it appears as though a primary factor with respect to human disease seems to be contact with 'backyard flocks' of avians, and not necessarily general exposure to migratory birds that may be infected.  It is now winter in Turkey, where temperatures drop low enough that the practice is for these 'backyard flock' avians to be brought into the same living quarters as the families that own them. This practice is thereby placing the diseased avian population in much closer proximity to humans.  In contrast, in Southeast Asia the avian population remains outside of the general living quarters so human to avian infected particle contact may be reduced from that seen when the same housing structure is shared.  Thus, this practice (bringing 'backyard flocks' into homes) may lead to an increased exposure to live virus.
The disproportionate levels of human and animal cases in Turkey points to 2 possibilities. Either the virus in Turkey is a new strain that is more easily picked up by humans, or it is the same strain but has been circulating for some time undetected. It is less likely that the virus has mutated to a more virulent form, as there was no increase in cases among the contacts of the 1st children who died of the disease in Van province. If we were dealing with a virus of a different characteristic, with higher transmissibility between humans, we would have 1st seen more cases among healthcare workers, among the playmates of these children, more cases in the village, than what we are seeing now. Contact between people and poultry has likely increased during the present cold weather, when the custom among many rural households is to bring poultry into their homes.
As of Jan 14, 2006, H₅N₁ has been discovered in poultry in 31 of the country's 81 provinces (tested positive in 13 provinces : all outbreaks in poultry occurred in backyard flocks which generally included chickens, geese, turkeys and ducks^{ref1, ref2}.
• eastern cities
• Agri province : 36 448 poultry killed and destroyed
• Dogubeyazit district
• Merkez village, since 31 Dec 2005 : susceptible 12,365 / cases 83 / deaths 83 / destroyed 12,282 / slaughtered 0; chickens and turkey analyzed with HI(2) on 7 Jan 2006 tested positive for H₅
• Eleskirt district
• Molla Huseyin village, since 25 Nov 2005 : susceptible 5601 / cases 12 / deaths 0 / destroyed 5601 / slaughtered 0; chicken and turkey analyzed with HI(2) on 6 Jan 2006 tested positive for H₅
• Hamur district :
• Asagi Yenigun village, since 29 Nov 2005 : susceptible 1260 / cases 25 / deaths 0 / destroyed 1260 / slaughtered 0; chicken, turkey and goose analyzed with HI(2) on 6 Jan 2006 tested positive for H₅
• Erzurum province
• Horasan district
• Camii Kebir village, since 30 Dec 2005 (avi) : susceptible 4439 / cases 350 / deaths 350 / destroyed 4089 / slaughtered 0; chicken analyzed with HI(2) on 4 Jan 2006 tested positive for H₅
• Merkez district
• Merkez village, since 2 Jan 2006 (avi) : susceptible 4430 / cases 35 / deaths 0 / destroyed 4330 / slaughtered 0; goose analyzed with HI(2) on 7 Jan 2006 tested positive for H₅
• Senkaya district
• Igdeli village, since 2 Jan 2006 (avi) : susceptible 324 / cases 10 / deaths 0 / destroyed 324 / slaughtered 0; chicken analyzed with HI(2) on 7 Jan 2006 tested positive for H₅
• Igdir province : 16 901 poultry killed and destroyed
• Aralik district
• Kopruler village, since 15 Dec 2005 (avi) : susceptible 2386 / cases 1214 / deaths 1214 / destroyed 1172  / slaughtered 0; chicken and duck analyzed with HI(2) on 26 Dec 2005 tested positive for H₅
• Merkez district
• Merkez village, since 28 Dec 2005 (avi) : susceptible 2287 / cases 358 / deaths 358 / destroyed 1929 / slaughtered 0; chicken analyzed with HI(2) on 4 Jan 2006 tested positive for H₅
• Erzincan province
• Bitlis province :
• Adilcevaz district :
• Aydinlar village (fau) : susceptible -- / cases 2 / deaths 2 / destroyed 0 / slaughtered 0; pigeon analyzed with HI(2) on 6 Jan 2006 tested positive for H₅
• Van province
• central cities
• Ankara province :
• Nallihan district :
• Cayirhan village, since 6 Jan 2006 (fau) : susceptible -- / cases 2 / deaths 2 / destroyed 0 / slaughtered 0; wild ducks analyzed with HI(2) on 8 Jan 2006 tested positive for H₅
• Yozgat province
• Akdagmadeni district
• Altili zaimgecidi village, since 2 Jan 2006 (avi) : susceptible 717 / cases 49 / deaths 49 / destroyed  668 / slaughtered 0; chicken and ducks analyzed with HI(2) on 7 Jan 2006 tested positive for H₅
• northwestern cities
• Bursa province
• Gursu district :
• Karahidir village, since 6 Jan 2006 (avi) : susceptible 120 / cases 20 / deaths 20 / destroyed 100 / slaughtered 0; chicken analyzed with HI(2) on 8 Jan 2006 tested positive for H₅
• Istanbul province
• S Urfa province (southeastern city of Sanliurfa)
• Hilvan district
• Ucuzler village, since 27 Nov 2005 (avi) : susceptible 300 / cases 200 / deaths 200 / destroyed 100 / slaughtered 0; chicken analyzed with HI(2) on 4 Jan 2006 tested positive for H₅
Outbreaks reported here range from small flocks of several hundreds birds to over 12,000 but do not appear to included highly concentrated, large commercial operations. The numbers of poultry killed or destroyed are small compared with the numbers seen in South East Asia. This outbreak may be just be in its initial stages, however, as we have a wide geographic range for the outbreak locations and not an overly large number of culled poultry to date. Probable bird flu cases in other 24 provinces : eastern cities of Mus and Elazig, northeastern cities of Kars, Rize, Ardahan, southeastern city of Diyarbakir, eastern city of Elazig and Mus, southern cities of Isparta and Osmaniye, western cities of Izmir and Aydin and central cities of Karaman, Sivas and Konya) and 455,000 birds have been culled. Teams with loudspeakers had been touring villages in the east telling people to give up their chickens, ducks, turkeys and geese or face fines of up to 100 YTL (USD 74). The cull was being largely supported by poor people in the region, because compensation of up to 15 YTL (USD 11) was being offered per bird destroyed.
The outbreak in Turkey is the worst since the outbreak in Hong Kong in 1997 when 18  people were infected and 6 died before it was brought under control. The huge number of animal outbreaks across the country is also perplexing. One theory is that migrating birds seeded the disease in various areas in late Dec 2005, but that is contradicted by the fact that no outbreaks have been reported in adjacent countries where the birds would also have passed. Another possibility is that poultry-selling practices in Turkey contributed to the spread. In Dogubayazit City, home to 4 of Turkey's 15 human A(H₅N₁) cases, people said the big chicken farms often send huge trucks of old birds to the town, selling them at low cost to poor farmers. The last truck arrived 2 or 3 weeks ago, they said. If even one bird on such a truck had bird flu, experts said, it could have quickly infected the others on board, disseminating A(H₅N₁) to many villages. Greece, which has banned all animal produce from Turkey, is spraying vehicles entering the country through its northeastern border with Turkey as a precautionary measure.
> 11,400 poultry and wild birds have died and 932,000 chickens have been culled^refin Turkey's current wave of the H₅N₁ virus, which according to WHO may have started with 3 dead pigeons found near the village of Caglayan in the eastern province of Erzincan on 21 Nov 2005^ref, despite Turkey, in a statement on 27 Dec 2005, said outbreaks began on 15 Dec 2005 in Igdir province, bordering Iran^{ref1, ref2}.
On Sun Jan 15 Syria culled any poultry on sale and any pigeons or game in an unregulated market  in the northeastern town of Kameshli near the Turkish border. Syria shares a 490 km (300 mile) border with Turkey. Scientists have said the virus could be spread by infected birds migrating south for winter. > 18,000 birds have been tested in Syria, and no human cases of bird flu have been reported. Iran culled 2600 free range birds in 9 villages in Maku, West
Azarbaijan province, banned poultry imports from Turkey and urged its citizens not to travel there. It has also closed its land frontier to single day cross border traders.
On Jan 14 32 patients are being treated at Van hospital, including 25 children and 7 adults, with a combination of antibiotics, intravenous fluids, and oseltamivir : some patients also require cardiac-management medication^ref.
Altogether 291 people are still hospitalised in Turkey for suspected bird flu—33 people, including 24 children, are being treated for the disease^ref.
On Tue 17 Jan, 2006, 5 patients with H₅N₁ had recovered and had been discharged from hospital. Many of the remaining 12 people are reported to be stable
Turkey is seeing a mortality rate of 20%, which is lower than the mortality rate observed in Asia, which was around 58% : anyway considering only the 12 cases confirmed by the WHO laboratory in London, the mortality rate is 33%^ref.
The famous and rare Turkish water-loving cats of Van, a protected species with white fur, auburn markings and different-coloured eyes : the Van Cat House conservation centre has closed its doors to visitors and is keeping its 100 animals indoors to prevent any possibility of them coming into contact with diseased airborne carriers^ref.
A 32 year-old French woman returning from a stay in the Tarsus region of Turkey, where she was travelling alone, is being treated on Jan 23, 2006, at Montpellier hospital for flu-like symptoms accompanied by breathing difficulties : initial diagnostic test on the woman had proved negative. The woman has been placed in an isolation ward and is receiving oseltamivir^ref.
No new cases since 13 Jan 2006 : the vast majority of cases have occurred in children aged 15 years or younger : this age pattern remains puzzling, as adult members in some families were engaged in such high-risk behaviors as the slaughtering of obviously ill birds yet did not develop infection. This observation further supports the possibility, raised previously during field investigations in Asia, that some as yet unidentified genetic or immunological factor may influence the likelihood of human infection^ref. Data on cases in the Turkish outbreak show that patients were hospitalized between 31 Dec 2005 and 13 Jan 2006. Dates of symptom onset indicate that all infections were acquired prior to the implementation of control measures. These have included heightened surveillance for poultry outbreaks, culling operations, intensive public information campaigns, contact tracing and prophylactic or post-exposure administration of oseltamivir, and good infection control practices in hospitals managing patients or investigating possible cases. In poultry, outbreaks of highly pathogenic H₅N₁ avian influenza are now confirmed or under investigation in numerous provinces across the country. Intensive culling operations are under way; some 1.3 million birds have been culled to date. As in many parts of Asia, the poultry outbreaks in Turkey have involved mostly free-ranging backyard flocks.
On Mon 30 Jan 2006 there were 67 localities in 31 cities (the last 2 being southwestern Burdur, central Anatolian Eskisehir and eastern Malatya) with confirmed AI. Meanwhile, the number of bird flu suspected cities dropped from 27 to 26, and localities from 73 to 66. A total of 1,596,000 poultry have been culled across the country due to bird flu so far^ref. In Turkey, 98% of the poultry is chicken. Of its approximately 300 million poultry, 10 million are raised in backyards. On Tue 31 Jan 2006, H₅ was detected in dead chicken in Igdir, near Turkey's far-eastern border with Armenia and 359 birds were culled^{ref1, ref2}.
As of 10 Feb 2006, 1.82 million poultry have been culled. The last 4 suspected AI human patients -- 2 of them confirmed to have contracted the deadly H₅N₁ strain -- were discharged from a hospital in eastern Turkey.
The European Commission has approved 8.35 million € for an emergency grant to Turkey, to fund programmes to control avian influenza there, with co-financing by the Turkish government. The Commission grant has been made available for investments in laboratory equipment, rapid tests, and safety equipment. This will help improve animal disease surveillance, diagnostic testing and rapid response capacity. There will also be a number of training and simulation exercises organised by the Turkish Veterinary Services and supported by the Commission^ref. A very long OIE report from Turkey which summarizes 39 outbreaks in 16 provinces, many of which have come to an end^ref. Turkey confirmed on Fri Mar 3 3 new cases of the H₅ strain of bird flu among poultry in an area to the west of Istanbul, in ducks and chickens in Catalca and Silivri, both near the Sea of Marmara on the western outskirts of Istanbul, a city of more than 12 million people^ref
New outbreaks:
• Istanbul province :
• Catalca division / Baklali Koyu village : since 24 Feb 2006 2 deaths
• Silivri division / Cemilbey village : since 27 Feb 2006 2 deaths
• Sinop province / Turkeli division / Karabey Koyu village : since 24 Feb 2006
• Diyarbakir province / Merkez division / Karacali Koyu village : since 12 Jan 2006 1541 susceptible / 15 cases / 15 deaths / 1526 destroyed
• Izmir province / Tire division / Alacali Koyu village : since 16 Feb 2006 6 deaths
Until now, only 1 outbreak has occurred in a commercial poultry unit in a small-scale commercial (broiler) poultry flock. All the other outbreaks have occurred in backyard (village) poultry flocks. Since Apr 6, 2006, 2 villages in Kars^ref (90 cases and deaths) and Yozgat^ref (4 cases and deaths) provinces report outbreaks in backyard poultry flocks. Source of new outbreaks: contact with infected animal(s) at grazing/watering and contact with wild animals. Between 15 Dec 2005 and 14 Apr 2006, a total of 2 503 516 poultry within the outbreaks and around the outbreaks were culled. Between 6 and 14 Apr 2006, 20 outbreaks in 5 provinces were eradicated^ref
Total : 21 cases (19 children in the age range of 4-18 years), 5 deaths (including 2 pairs of siblings).
Web resources :
• The European Commission Joint Research Centre (JRC) Response to Emergencies and Disasters : Avian flu
• A map demonstrating Turkey's confirmed and suspected HPAI outbreaks in poultry, as of 17 Jan 2006
• Cyprus : on Mon 23 Jan 2006, samples from a dead turkey and a chicken were taken from close to Incircli, a village on the eastern part of the island, which is also known by the Greek name Makrasykas. [Latitude 35.0750, Longitude 33.7667^ref] : they tested positive on Jan 29^ref. Since then, the Turkish Cypriot authorities have killed around 1200 poultry within a 10 km (6 mile) radius of the village where the dead birds were found^ref. The introduction of the virus into the Turkish-controlled northern part of Cyprus could have been brought about by (illegally) imported avians or their products; infected wild birds may also be considered. Cyprus is divided into a prosperous, internationally recognised Greek Cypriot south and a smaller, poorer Turkish Cypriot north which is recognised only by Turkey. Despite continued international trade restrictions, the north's economy has grown strongly in the past few years, propelled mainly by tourism, construction and real estate. Official figures show gross domestic product (GDP) in the self-declared Turkish Republic of Northern Cyprus (TRNC) leapt 31% in 2004 to 7350 USD per head -- still small compared to the Greek Cypriots' 21 000 USD but a big jump from a low base. North Cyprus does not export chicken. A surveillance zone around the infected village of Incirli had been widened to 10 km (6 miles) from 3 km
• Syria : a 5-day assessment visit to Syria by officials from the WHO and FAO found no evidence of bird flu^ref
• Israel^{ref1, ref2, ref3} : the concern of authorities is understandable in view of Israel's geographical situation as a crossway of migratory birds on their route from Asia and Europe to Africa. The number of birds annually migrating through Israel in each direction is estimated to be around 500 million^ref. Recoveries of birds ringed in other countries are rare in the region owing to the small number of banding sites in Asia in general and the eastern Mediterranean basin in particular (Ozarowska, A., R. Yosef and P. Busse (2004). Orientation of Chiffchaff (Phylloscopus collybitta), Blackcap (Sylvia atricapilla) and Lesser White-throat (S. curruca) on spring migration at Eilat, Israel. Avian Ecol. Behav. 12:1-10; Yosef, R. (1997).  Clues to the migratory routes of the eastern flyway of the Western Palearctics - ringing recoveries at Eilat, Israel (I - Ciconiiformes, Charadriiformes, Coraciiformes, and Passeriformes).  Die Vogelwarte 39:131-140; Yosef, R. (1998). Clues to the migratory routes of the Western Palearctics - ringing recoveries at Eilat, Israel (II - Falconiformes).  Die Vogelwarte 39:203-208). Hence, use of ring recoveries alone can be misleading.  This was shown in orientation experiments where, although 100% of all Chiffchaffs (Phylloscopus collybitta) controlled outside Israel were in western Europe, 87% of the individuals included in the experiment at Eilat oriented northeast and eastnortheast, suggesting breeding grounds in Asia (Ozarowska, A., R. Yosef and P. Busse (2004). Orientation of Chiffchaff (Phylloscopus collybitta), Blackcap (Sylvia atricapilla) and Lesser White-throat (S. curruca) on spring migration at Eilat, Israel. Avian Ecol. Behav. 12:1-10.). Ring recoveries of Flamingoes (Phoenicopterus rubber) in the 1970s (Shirihai, H. 1996. The Birds of Israel. Acad. Press. London, Yosef, R. (1997). Physical distances among individuals in flocks of Greater Flamingoes (Phoenicopterus ruber) are affected by human disturbance. Israel J. Zool. 43:79-85) were from Iran, but  in recent years all of the 1st-year birds that winter in the saltpans of Eilat are from the breeding colonies in Izmir, Turkey (RY, unpubl. data). Raptors originate in the Black Sea region and further east, including Levant Sparrowhawks (Accipiter brevipes), Steppe Eagles (Aquila nipalensis) and Steppe Buzzards (Buteo buteo) (Yosef, R., P. Tryjanowski and K. Bildstein (2002). Spring migration of adult and juvenile Buzzards Buteo buteo through Eilat, Israel: timing and body size. J. Raptor Res. 36:115-120; Yosef, R., L. Fornasari, P. Tryjanowski, M. Bechard, G. Kaltenecker, and K. L. Bildstein (2003). Differential spring migration of adult and juvenile Levant Sparrowhawk Accipiter brevipes through Eilat, Israel. J. Raptor Res. 37:31-36; Yosef, R., and L. Fornasari (2004).  Simultaneous decline in Steppe Eagle(Aquila nipalensis) populations and Levant Sparrowhawk (Accipiter brevipes) reproductive success: coincidence or a Chernobyl legacy?  Ostrich 75:20-24), Booted Eagle (Hieraaetus pennatus), Black Kite (Milvus migrans), Marsh Harrier (Circus aeruginosus), and Eurasian Sparrowhawk (A. nisus), (RY, unpubl. data). Waders (Wood Sandpiper Tringa glareola; Common Greenshank T. nebularia, Green Sandpiper T. ochropus, Little Stint Calidris minuta) ringed at Eilat are recovered in Eastern Europe and in the Arctic (Yosef, R., P. Tryjanowski and M. Remisiewicz (2002). Migration characteristics of Wood Sandpiper (Tringa glareola) at Eilat, Israel. The Ring 24:61-69; Yosef, R., M. Malkinson, C. Banet-Noach and R. King (2005). Israel: West Nile Virus antibodies in recently fledged arctic Little Stints (Calidris minuta). ProMED Mail 3 Feb. 20050203.0377. <http://www.promedmail.org). White (Ciconia ciconia) and Black (C. nigra) Storks, White Pelican (Pelicanus onocrotalus) and Great Cormorant (Phalacrocorax carbo) also migrate from Central and Eastern Europe and western Asia through the Levant in large numbers (Leshem, Y., and Y. Yom-Tov (1996). The magnitude and timing of migration by soaring raptors and storks over Israel. Ibis 138:188-203), some even wintering in central and northern Israel. Passerines that frequent aquatic habitats in Eastern Europe and west of the Ural Mountains also stop over or winter at Eilat:  Reed Warbler Acrocephalus scirpaceus, Sedge Warbler A. schoenobaenus, Bluethroat Luscinia svecica, Reed Bunting Emberiza schoeniculus, White Wagtail Motacilla alba^{ref1, ref2, ref3, ref4, ref5} (Langer, Y., and A. Rochman (1991). Recoveries of Pied Wagtails Motacilla alba in Israel and abroad. Sandgrouse 13:49-53; Markovets, M., and R. Yosef (2005). Phenology, duration and site fidelity of wintering Bluethroat (Luscinia svecica) at Eilat, Israel. J. Arid Environ. 61:93-100; Meyrom, K., R. Yosef, and P. Tryjanowski (2001). Phenology and biometrics of migratory Reed Bunting (Emberiza schoeniclus) in Israel. Israel J. Zool. 47:161-165; Yosef, R., and N. Chernetsov (2004).  Stopover ecology of migratory Sedge Warblers (Acrocephalus schoenobaenus) at Eilat, Israel. Ostrich 75:52-56; Yosef, R., and N. Chernetsov (2005). Longer is fatter: body mass changes of migrant Reed Warblers (Acrocephalus scirpaceus) staging at Eilat, Israel.  Ostrich 76:142-147). Other Passerine species originate from areas to the north and east of Israel, e.g. Red-backed Shrike Lanius collurio, Masked Shrikes Lanius nubicus, Ortolan Bunting Emberiza hortulana, Crzetzschmar's Bunting E. caesia, Dead Sea Sparrow Passer moabiticus^{ref1, ref2, ref3, ref4, ref5} (Tryjanowski, P., and R. Yosef (2002).  Differences between the spring and autumn migration of the Red-backed Shrike Lanius collurio: record from the Eilat stopover (Israel). Acta Ornithologica 37:85-90; Yosef, R., and P. Tryjanowski (2002a). Differential spring migration of Ortolan Bunting (Emberiza hortulana) by sex and age at Eilat, Israel.  Ornis Fennica 79:173-180; Yosef, R., and P. Tryjanowski. 2002b. Spring migration ecology of the Crzetzschmar's Bunting (Emberiza caesia) through Eilat, Israel. Israel J. Zool. 48:149-153; Yosef, R., and P. Tryjanowski (2002c). Migratory Masked Shrikes Lanius nubicus staging at the desert edge: phenology, and sex- and age-related differences in body mass. The Ostrich 73:162-165; Yosef, R., P. Zduniak, and P. Tryjanowski (2004). Age, sex and season related biometrics of the Dead Sea Sparrow (Passer moabiticus).  Ardeola 51:297-302).  Other species, although no bands have been recovered, can be identified to the sub-specific level and indicate their Far Eastern origins, e.g., Stonechat Saxicola torquata maura or S. t. variegate, Isabelline Shrike L. isabellinus isabellinus. Near-Passerines that breed in the Levant also migrate through Eilat: European Bee-eater Merops apiaster (Yosef, R., M. Markovets, L. Mitchell and P. Tryjanowski (2005). Stopping at the stopover ­ the drop-out hypothesis: a case study in Bee-eaters at Eilat, Israel.  J. Arid Environ. 62:In Press), Quail Coturnix coturnix, and Turtle Dove Streptopelia turtur There is always the possibility of a number of new, vagrant and accidental species turning up at Eilat from the infected regions to north and east of Israel (Yosef, R., and M. Rydberg-Hedaen (2002).  First ringing record of Pied Stonechat Saxicola caprata in the Western Palearctic, at Eilat, Israel. Sandgrouse 24:63-65; Yosef, R., and P. Tryjanowski (2002d).  Avian species saturation at a long-term ringing station ­ a never-ending story? - J. Yamashina Inst. Ornithol. 50th Anniversary issue. 34:89-95). Placing all the "blame" on migratory species  could also be problematic in light of the fact that even those that appear to be sedentary (eg., House Sparrow Passer domesticus, Bulbul Pycnonotus xanthopygus) exhibit great coverage of geographical areas during the dispersal period immediately after their breeding season. Birds we considered sedentary in Eilat, and ringed as fledglings in the IBRCE Bird Sanctuary, have been recovered as far to the east as the Jordan-Iraqi border. As H₅N₁has been shown to affect a range of avian families and, as shown here, species of many bird families traverse Israel during migration, monitoring and sampling should be applied in relation to birds originating from several directions, and not be restricted to birds assumed to originate from the breeding areas to the north of the Levant. The present "trail" of infections found from Kazakhstan and Russian territories towards Turkey, Romania and Croatia indeed follow the north-south migratory routes of wild birds, but this in itself cannot be taken as proof for migratory bird populations spreading the virus. Since sick and dead birds cannot migrate, it is possible that individuals in the early stages of infection are those that are able to migrate in the direction of their wintering grounds and in this way a relay-style transfer could be detected to spreading along the migratory flyway.  However, unlike other infections (e.g. West Nile Virus), sampling of migratory birds has failed to turn up significant numbers of asymptomatic H₅N₁ carriers. Yet, an OIE expert delegation to Russia has obtained from the All-Russian Reference laboratory a list of infected wild birds (waterfowl, waders, crows, raptors, pigeons) sampled in several districts of the Omsk Region; similarly to the EMPRES guidelines, the list includes also species of Passerines and near-passerines. It might be suggested that H₅N₁ is, most probably, lethal to wild avian populations and  -- similarly to our results for West Nile Virus -- infection is neither habitat- nor taxonomic-related.  We sampled 1703 birds from 59 species in autumn 2001 and spring 2002 at Eilat and, although the overall average infection rate was 8%, the highest levels were found in species independent of habitat or taxonomy. Highest levels of infection were in Eurasian Sparrowhawk A. nisus 33% (2 of 6), Water Rail Rallus aquaticus 33% (4 of 12), Red-rumped Swallow Hirundo daurica 28% (5 of 18), Rufous Bush Robin Cercotrichas galactotes 25%, Wryneck Jynx torquilla 20% (2 of 10),  (2 of 8), Bluethroat Luscinia svecica 18% (46 of 156), Dunlin C. alpina 14% (6 of 44), and Barred Warbler Sylvia nisoria 15% (6 of 41). I cannot stress enough that, based on the paucity of information of the biology of H₅N₁, our old assumption that wild populations are not susceptible to viral infections, particularly to H₅N₁, is most probably wrong, and that this might be true in relation to multiple avian families.  Hence, sampling restricted to habitat- or taxon-specific parameters could result in a biased understanding of the environmental processes. The guidelines also restrict their sampling mostly to waterfowl and a small number of aquatic or pelagic species, as suggested by most of the action plans (WHO, EMPRES, EU surveillance guidelines, etc.). The impression from these guidelines is that the major infection is in waterfowl even though other families have also been infected^ref. The conclusion about duck, geese, turkey and chicken is most probably derived from, and influenced by, their being in the domestic poultry industry.  Also, cross-border trade in poultry and wildlife can contribute considerably to the spread of the virus. Partial proof for this is the fact that most of the infections initially detected in Russia and Mongolia were along railway lines and human settlements. Even though autumn migration had not yet started and bird migrations were still very restricted, dispersal of juveniles was random, and no unidirectional mass movement has developed in the direction of the wintering grounds.  Waterfowl are also at the top of the list as game birds that are hunted extensively, and that factor might bias our understanding of the true nature of the spread of Avian Influenza. Further sampling should not be restricted to birds found dead or freshly hunted as suggesed by existing action plans, but instead be performed on a daily basis, from a wide range of species. It is important that professionals undertake sampling to ensure adherence to the strict protocols that govern the capture and handling process and to ensure hygiene standards that will preclude infection to the handlers. It is also of great importance that sampling not be restricted to a given region, e.g., northern Israel, because many of the eastern species cross Israel at more southern points.  The lack of ilat band recoveries in the rest of Israel indicates that there are different points of entry of the migratory bird populations along the length of the country (Bear, A., and R. Nitzan (1999). Summary of bird recoveries in Israel from 1845 to 1998. Torgos (suppl.) 31pp.; Frumkin, R., B. Pinshow & S. Kleinhaus (1995). A review of bird migration over Israel. J. Ornithol. 136:127-147) and that not all the migratory flyways which criss-cross the Middle East have as yet been identified. The greatest risk of human infection with avian flu has, so far, been attributed to close contact with infected birds -- particularly, with blood, saliva or droppings. Hence, possible contact with birds should also be avoided in zoos, educational facilities that keep captive birds, and holdings of backyard chickens, ducks and geese. The latter, and certainly commercial poultry, should be kept indoors and under strict supervision until the migration season is over in early-December. The exact role of migratory birds in the international transfer of the virus is still to be scientifically elucidated.  It is not to our advantage, nor to that of our environment of which humans are a part, if extreme measures (e.g., extermination of whole populations, draining of wetlands, etc.) are advocated without the welfare of wildlife being considered appropriately. There must be inter-disciplinary cooperation, which includes avian migration researchers in addition to physicians and veterinarians, in our communities such that not only a human pandemic is prevented but also the obliteration of our global biodiversity not threatened by extreme measures by the human race.
• a 57-years old Galilee resident experienced high fever (40°C/104°F), cough, headache, weakness, pneumonia and slight diarrhoea, after several days was hospitalized at Rebecca Sieff Hospital in Safed on Nov 20, 2005 recovered and will be released Fri 25 Nov. In addition, tests carried out by the Agriculture Ministry on birds in the Lake Hula nature reserve, where the man feeds birds, did not find any birds carrying the virus. Samples were sent to the Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel-Hashomer. Real-time PCR and RT-PCR of pharyngeal swabs for H₅ were applied with negative results; the testing of bronchoalveolar lavage, which requires invasive procedures, was considered but was found not justifiable in view of the improvement in the patient's condition. When the serological test (HI) was later found positive, the decision was made to repeat the tests and to send serum samples to the at Sheba Medical Center, Tel Hashomer, and in England. Blood tests for antibody will not identify virulent H₅N₁, only the sequencing of PCR-amplified genome will. Even a seroconversion between his early and late blood samples, or the finding of IgM antibody, would not prove conclusively that his illness was due to H₅N₁ virus; he might have had a mild infection and his pneumonia could have been due to a different cause
• a resident of a Palestinian West Bank village located east of Jerusalem arrived at Hadassah Ein Kerem hospital’s emergency room on Mon Jan 16, 2006 for fear he contracted the bird flu. Several of the chickens owned by the man died in recent days, hospital sources said. He was placed in an isolated room and is receiving medical treatment^ref
In view of Israel's situation as a main flyway of migratory birds between Europe, Asia and Africa^ref, the Israeli Veterinary Services have undertaken (passive) surveillance in dead wild birds since fall 2005. All tests of (an unspecified number of) dead wild birds, carried out by the central Veterinary poultry laboratory at the Kimron Veterinary Institute, Beit Dagan, have been -- so far -- negative.
• on Thu 16 Mar 2006 night 11,000 fattening turkeys 16 weeks old and 5,000 chickens died from suspected H₅N₁ in the southwestern Negev Desert farming communities of
• Ein Hashlosha / En Hashelosha Kibbutz : susceptible: 12,000 deaths: 1800 : Yedioth Ahronoth newspaper reports about 5 Israel citizens from Ein Hashlosha. At the same time Haaretz informs of 4 workers, including^ref :
• a Thai laborer who worked at the Kibbutz and came into contact with the infected turkeys was sent to Soroka Hospital in Be'er Sheva to determine whether they had contracted the deadly bird flu strain^{ref1, ref2} and is being held in isolation
• another patient sent at Barzilai Hospital in Ashkelon^ref
• Holit Kibbutz^{ref, ref2}: susceptible: 30 000 deaths: 9000
• 2 Bedouin from the Tel Arad region who worked at the Kibbutz were sent to Soroka Hospital in Be'er Sheva to determine whether they had contracted the deadly bird flu strain^ref. They had been feeling sick for the past few days but could not get off work.
Test results on the 4 were negative on Sat 18 Mar 2006^ref. The veterinary authorities imposed a quarantine with a radius of 7 km around the 2 Negev kibbutzim where the birds were found dead -- Ein Hashlosha and Holit -- and 2 neighboring kibbutzim, Nirim and Kissufim. The quarantine means that no birds can enter or leave the kibbutzim, and no people will be allowed into the coops except those who must care for the birds that are still alive. These essential personnel are required to don suitable protective gear -- masks, goggles and protective clothing -- before entering. Culling of birds (only half of all birds at Holit and 1/3rd of those at Ein Hashlosha) in infected coops was completed Sun 19 Mar 2006. Culling of the fowl began Mon 20 Mar 2006 at Kibbutz Sufa near Holit, and at the Kissufim and Nirim kibbutzim near Ein Hashlosha^ref. In addition, a quarantine will be imposed with a radius of 10 km around the kibbutzim. Anyone who was in contact with the affected birds ought to be given immediate preventive treatment. At Ein Hashlosha that could include more than just farmers and veterinarians, since there, the coops are inside the kibbutz, so the virus surely exists in every nook and cranny. The 2 affected farms are adjacent to the Gaza strip, within the Palestinian authority
• Kibbutz Nachshon / Nahshon near Beit Shemesh, on Mar 17^ref, about 80 km to the northeast of Ein Hashlosha and Holit and only 25 km west of Jerusalem, where suspicious deaths among turkeys had been noted over the last 2 days^ref: susceptible: 20 000 deaths: 500. Culling started on 21 Mar, including Kibbutz Harel and the Tekoa and Tzalfon moshavim nearby^ref
• Moshav Sdeh Moshe, at the Lachish-area near the southern town of Kiryat Gat^{ref1, ref2}: susceptible: 6500 deaths: 500. Culling of birds in infected coops was completed Sun 19 Mar 2006^ref.
• Kibutz Nir-Oz^ref, adjacent to Ein-Hashlosha, close to the Gaza strip^ref : the Israeli TV stated, on Sun 19 Mar 2006 evening, that a 5th outbreak has been suspected in a turkey farm^ref, which tested positive on Mon Mar 20, 2006^ref
• Kibutz Moshav Amei Oz^ref in southern Israel : turkeys tested positive on Mon Mar 20, 2006^ref
• moshav Beqaot, the Jordan Valley. Initial PCR tests indicated H₅ on Wed 22 Mar, 2006, but in view of the low mortality observed, tests were repeated^ref and confirmed H₅N₁ on Thu Mar 23, when the Veterinary Services began culling the flocks in the 4 poultry coops in the community^ref. The broiler farm, 4 km from Ein Hashlosha, is a 160,000 broilers unit with 13 chicken houses of different types from controlled environment to conventional. The flock was about 40 days of age, and part of it was already sent to the slaughterhouse. Despite the fact that the PCR results proved negative in the sample tested, 2 days after the samples were taken, a sudden increase in mortality was observed in one out of 10 chicken houses. In a house containing 16,000 broilers, mortality increased from 10 birds per day to 400 the next day to >800 by the 2nd day. The only clinical signs within the flock were the sudden mortality of apparently well-developed birds, with severe signs of cyanosis and ischemia in the wattles, the comb, the legs and the skin of the belly. The tarsal and metatarsal areas were swollen and purple in color. Post mortem examination did not reveal any special macroscopic change, and only in some birds a slight grayish discoloration of the pancreas could be seen. Tracheal and cloacal swabs taken from sick birds proved positive by PCR test to the H₅N₁ HPAI virus.
• dead birds were found in the central Israel town of Netaim on Mar 24, though test results are pending^ref
• the Arab village of Ouja near Jericho has also reported dead birds, which are now being tested^ref
• Kibbutz Ma'aleh / Maaleh Hahamisha (about 10 km north west of Jerusalem) : on Mar 28, 2006, 30,000 chickens at the farm were quarantined and poisoned when initial tests showed some of the birds had contracted H₅N₁ virus^{ref1, ref2}. This outbreak occurred in a broiler breeder farm (40 weeks of age). The (initial) mortality rate was very low (40 out of 30 000 birds in 6 buildings). The preliminary initial H₅ diagnosis and its confirmation as H₅N₁ were obtained by PCR at the Kimron Veterinary Institute, Beit Dagan. The Israeli government approved compensation of 15 million shekels (USD 3.1 million) to farmers of affected areas^ref
• Kibbutz Kerem Shalom, near Israel's border with the Gaza Strip and Egypt : tests confirmed on 31 Mar, authorities began culling 20,000 chickens^ref
• Jerusalem (30 000 birds)
• HaDarom^ref (20 000 birds)
Vaccination is prohibited except for birds of species listed in Appendix I of the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES) living in zoos, which are vaccinated with inactivated H5N2 vaccine (Nobilis, Intervet, Holland), and a flock of 14 000 ostriches (breeder flock) in the south of Israel, which is the only commercial flock being vaccinated. The aforementioned vaccinations were performed in accordance with Commission Decision 2005/94/EC, dated 21/10/05.
8 of the outbreaks, including the current one, are close to the Gaza strip or might have had contacts among them. One outbreak, in the Jordan valley (Beqaot), is rather distant while sharing the same ecological/geographic situation, and a major flyway, with the affected location in neighbouring. The poultry was culled with water containing poison. The government will compensate the farmers for their significant financial losses. Turkey poults are usually reared commercially in open-meshed, wire net barns/houses. A typical barn will house 2500-4000 birds; some enterprises maintain 8-15 such barns, or even more. Significant quantities of faeces are produced in those facilities. When located within inhabited areas, close to human dwellings, dusty faecal material may be windborne to a certain distance. This may reach other animals and/or man. For this reason, in most villages in Israel most turkey barns have been moved to distant, uninhabited locations. Unfortunately, there are exceptions.  In "normal" times, the nuisance there may be limited to allergic or breathing problems. However, if/when the turkeys are HPAI infected, the possibility that their airborne exrements might expose the local human population to infection may deserve consideration^ref. Health authorities decided to fly 4 million doses of bird flu vaccine into Israel from The Netherlands^ref, but the number of domestic avians (mainly turkeys and chickens) to be vaccinated is at least 10-fold higher than the number of doses of the Dutch vaccine^ref. On 26 Mar 2006, Israel's Agriculture Ministry inspectors and Defense Ministry contractors completed the culling and burial of about 1.2 million fowl suspected of contracting bird flu in 13 agricultural settlements in the western Negev, the Lachish region, the Jerusalem corridor, and the Jordan Valley over the weekend. Culling of poultry on Moshav Amioz in the western Negev is to be completed on Sun 26 Mar 2006^ref.
Not finding many dead wild birds does not mean birds are not dying from the disease. This is because, as a rule, it is very difficult to find dead wild animals of any kind. When they are just starting to feel sick, their behavior signals this to their predators, and they are predated. And if they are not detected by predators but die of the disease, scavengers and bacteria take care that, in a short while, nothing is left to find. Only for large animals (say swans) is the story different, since they don't have many predators, and it takes more time for the dead body to disappear. I did not see, however, studies that compare spread of pathogens between territorial and colonial birds. Also, territorial birds become non-territorial in the non-breeding season and may then roost in big aggregations. And, when on desert-crossing migration, many birds alight to rest and refuel in small oases. There, individuals that otherwise always keep a distance from each other come in nearly direct contact with each other for a few days. Again, I do not know of studies that compared the incidence of bird pathogens in desert oases with the incidence in migratory birds off oases. Eilat can be regarded as an oasis, and the US group that took blood samples
of migratory birds there decades ago did not have another research site away from Eilat. As to the Jordan valley cases: it is spring migration now, and the birds come from Africa. It is likely that the area between the eastern Mediterranean coast and the edge of the desert in Jordan is used by more migrants coming from Africa than more northern areas, because by traveling through this area, they can alight and feed/rest. This cannot be easily done if they go through the Arabian Desert. But many small birds cross the Mediterranean, and actually fly at night in a wide front, not necessarily being funneled to a specific route, but rather take the shortest way to where they breed in central and northern Europe and the fertile parts of west Asia. Soaring birds, on the other hand, avoid the Mediterranean and concentrate along its eastern land mass (Israel, Jordan, Lebanon, Syria), namely all birds of prey, storks and pelicans. They come after a desert crossing, and especially storks tend to stay for feeding in Israel before completing the journey to central Europe. What the wildfowl are doing -- geese, ducks -- I am not sure. Maybe they also circumvent the sea, and hence we (Israel) get more of them. We also have birds that were not with us in the winter and return now from Africa to breed.
Israel suspects journalists, particularly press photographers, of being behind the spread of deadly bird flu in the Jewish state. Bird flu can be transmitted on clothing, footwear, the wheels of cars and even on cameras : the journalists who came to cover the outbreak then went back to homes and offices across the country. Even if the required protective measures were taken, it is impossible to disinfect photographic equipment without damaging it^ref.
The ministry has shelled out > USD 4.7 million to poultry farmers in 25 kibbutzim and moshavim in Israel : USD 17 for a turkey, USD 3 per chicken and 44 cents per chick^ref. On 1 Apr 2006, the animals of the last infected flock were culled and buried. Since that date, no further cases of HPAI H₅N₁ have been diagnosed in Israel. The restrictions will be lifted on 8 Jun 2006. The cleaning and disinfection of infected holdings and all the holdings within the 3-km-radius zone were completed on 1 May 2006. After the cleaning and disinfection of all the empty holdings, 30 days will elapse before repopulation in the protection zone. On 22 Apr 2006, the first holding was repopulated in a surveillance zone. In total 1 120 000 birds in 53 commercial farms were destroyed in 15 localities within 9 days. Pits were dug 6 metres deep on each of the sites. None of the destroyed birds were moved from the premises. Nylon sheets were placed on the bottom and sides of the pits. After finishing the disposal of the dead birds, the pits were covered with lime and closed^ref.
• Palestinian authority (Gaza strip)^{ref1, ref2} : on Feb 20, 2006, a chicken farm in northern Gaza reported that 300 chickens have died^ref, but after testing negative for AI, it is suspected to have been an outbreak of Newcastle disease^ref. On Wed 22 Mar 2006, H₅N₁ was found in the eastern village of Juhr al-Dik. On Mar 23 H₅N₁ was found in coops built on the ruins of the former Jewish settlement of Beqaot / Netzarim (evacuated by the Israeli army in 2005), near Gaza city on the Jordan river^ref the West Bank in the central Strip^{ref1, ref2}: the birds were tested by Israel in rare cooperation (despite plummeting relations as Hamas prepares for government) and a quarantine has been imposed on a farm in the settlement where about 20,000 chickens were being raised^ref. On Mar 24, 2006, the H₅N₁ virus was discovered in 200 chickens found dead on Mar 22 in Rafah (the southern Gaza town known for its weapons smuggling tunnels)^ref, in the southern Strip on the border with Egypt^ref1 : government officials told them they would not be compensated for culled birds. The 2 affected farms have a total of 80 000 chickens^ref. The Gaza strip, bordering Egypt (11 km border) and Israel (51 km border), stretches across an area of about 40 by 9 km, namely 360 sq km -- slightly more than twice the size of Washington, DC. With a population of about 1.4 million, it is one of the most densely populated territories in the world. The Agriculture Ministry of the Palestinian Authority is preparing to cull 80,000 fowl in the center and the south of the Strip^ref. : agriculture officials began poisoning 15 000 chickens in the Gaza Strip on Mon^ref. On 26 Mar there were a further 2 suspected cases in El-Bureij in the center and Beit Lahia in the north^ref. The  recent closures of the Karni border crossing with Israel have limited the import of alternative protein sources, further increasing concern over a nutrition gap in the Palestinian food supply. Some 250,000 birds have been culled by UN officials and PA agencies so far. The figure represents 10% of the total estimated number of fowl in the Gaza Strip. > 30,000 farmers lost their chickens to the culling and were left unable to provide for their estimated 200,000 family members. An additional 250 000 birds were slated for culling. If Israel would allow fishing off the Gaza coast, it could add sardines, a cheap protein source, to the Palestinian market. The PA needed doses for at least 3% of its population just to deal with the direct threat of infection, at a cost of some USD 2 million^ref. As of Apr 5, 8 farms in Gaza have been affected in the North, South and Middle districts.  4 farms reported the number of susceptible birds which ranged from 1900 to 29 000. Contact with wild birds is suspected^ref

Jordan^{ref1,ref2, ref3} : on Mar 24, 2006, the H₅N₁ was found in 3 (4?^ref) turkeys at a domestic farm in the Kufranjeh / Kufranjeh / Kofranja (synonyms: Kefrenji, Kefrenjy, Kufrinja, Kufrinjah, Kufrinje, Kufrinji), Lat 32.2972, Long 35.7031^{ref1, ref2, ref3}, situated 5 km south west of Ajlun / Ajloun, 14 km east of the Jordan valley, about 65 km north of Amman, at 23 km air-distance from Beqaot, the Israeli settlement on the opposite, west side of the Jordan river, where AI was detected in turkeys on Wed 22 Mar 2006. The relative proximity of the 2 locations, among which no contacts are known, both located within the Jordan valley -- a major flyway -- might give room for speculation that a common, migratory-birds origin of the infection might be in the background. This could be further investigated by molecular sequencing of the isolates from both outbreaks, comparing them with other recent isolates from the region. So far, no isolates have been obtained from wild birds in Israel, Jordan or the Palestinian Authority territories. Number of animals in the outbreak: 21 cases -- including the 20th death from a flock of 8000 -- are reported. The animal health officials destroyed another 1500 birds. The affected population was backyard poultry (turkeys and chickens)^ref. Authorities began early that day to destroy birds within a 3-km radius^ref. 20 (22?^ref) people were given oseltamivir and the area has been cordoned off to prevent the disease from spreading further. Jordan began culling birds within a 6-km (4-mile) radius of the outbreak on Fri Mar 24 : birds further away will be vaccinated^ref. Officials ordered people in the Jordan Valley to eat poultry from their farms within a week or risk of having their birds culled. Jordan imported 60,000 doses of Tamiflu^ref. Teams from the ministries of health and agriculture and municipalities are destroying birds within a 6 km radius of Kufranjeh. In addition, they are vaccinating birds within a 10 km radius of the village. So far, > 2500 birds in the area have been culled : on 25 Mar 2006 the entire Kingdom was included in the deadline issued to Jordan Valley residents : pet birds kept indoors would not be included. Only chickens, doves and turkeys will be affected because they live in open places and are not well-protected. > 20 000 chickens wer culled in 4 poultry farms in Kufranjeh, on 26 Mar 2006. In central Jordan Valley, the Public Works and Housing Department, in cooperation with local municipalities in the area, have started digging trenches (3 metres deep, 15m long, 10m wide) close to poultry farms in the area, which contain > 100 000 chickens : if the deadly virus is detected in the area, they will cull the poultry and bury them in these trenches^ref. Contrary to the earlier outbreaks in southwestern Israel and in the Gaza strip, where the virus is suspected to have been spread by humans, mechanical means, or contaminated subjects and materials, the 2 outbreaks on both sides of the Jordan river might be attributed to migratory birds, since the Jordan valley is a major flyway. 3 weeks after the initial outbreak, an ongoing national surveillance programme for wild birds and domestic poultry has not detected any further infections^ref
• Europe :  animal disease situation by country and disease. The following data pertain to the number of reported HPAI cases identified in wild birds between 1 Jan 2006 and 12 May 2006. In brackets is the last date of confirmation^ref.
• Austria 46 (2 May)
• Bulgaria 4 (27 Feb)
• Switzerland 9 (20 Apr)
• Czech Republic 12 (14 Apr)
• Germany 207 (3 May). Also one HPAI outbreak in domestic fowl (5 Apr)
• Denmark 25 (2 May)
• France 21 (25 Apr). Also 1 HPAI outbreak in domestic fowl (25 Feb)
• Greece 25 (22 Mar)
• Hungary 12 (13 Mar)
• Italy 15 (25 Mar)
• Poland 28 (8 Apr)
• Romania 10 (31 Mar . Also 30 outbreaks in domestic fowl (27 Mar)
• Sweden 10 (10 Apr). Also one outbreak in domestic fowl (17 Mar)
• Slovenia 28 (22 Mar)
• Slovakia 2 (24 Feb)
• United Kingdom 1 (6 Apr)
The above figures differ in some cases from figures from other official sources. For example, Switzerland's official, detailed website mentions, in its update of 21 Apr 2006, 32 "avian influenza positive" wild birds. The 23 which are not included in the ADNS table have been identified as H5; their N type has not been analyzed/determined. Though the table includes a separate column for LPAI in wild birds, not a single positive case is to be found in this column. On the other hand, there were 3 LPAI detections in domestic fowl: all 3 reported from the UK, with the last date of confirmation being 5 May 2006. ADNS covers EU member states and other countries connected to the application. The reviewed ADNS table includes, in addition to the above 16 countries, also 16 countries which have not reported, during 2006, any positive HPAI case in domestic or wild birds: Andorra, Belgium, Cyprus, Estonia, Spain, Finland, Faroe Islands, Ireland, Lithuania, Luxembourg, Latvia, Malta, Netherlands, Norway, Portugal. It would be helpful if ADNS, or another EU institution/agency, could obtain and publish figures and species of the wild birds tested by all participating countries, infected and not-infected, within their respective surveillance projects, and specify the species of the positive wild birds^ref. The presented data in the table are an example of numerator bias. Many of these "positive" birds were collected for diagnostic purposes in a non-standardized fashion primarily to determine whether H5N1 virus was present, yes or no. There are no standards for the denominators. Those comparing 40+ve birds in one country of whatever species are hard to correlate with 5+ve birds in another. Plus, as we know, the harder one looks, the more one finds. In some respects, if one presumes on a minimal standard for sick bird surveillance, the absent reports may have more
interpretive weight than the positive reports. Clearly, we still have a way to go in sorting out what is happening, likely to happen, and what the true risks are
• Hungary^ref : a major goose-liver producer/exporter. dead pigeons in Szeged, near the Romanian border, on the banks of the river Tisza which also flows through Romania. 13 cases :
• 3 wild swans were found dead on the ice of the Danube near Esztergom on 15 Feb 2006 : they tested positive for H₅ on Feb 14 and for H₅N₁ at VLA, UK on Feb 21^{ref1, ref2}
• 3 swans from near the village of Nagybaracska and Csatalja, in the county of Bacs-Kiskun (Vats-Kiskun) Department, southern Hungary (about 100 miles south of Budapest) : they tested positive for H₅ on Feb 14 and for H₅N₁ at VLA, UK on Feb 21^{ref1, ref2}. Bacs-Kiskun, crossed by the Danube river, is situated in south Hungary, bordering Serbia^ref : it is an important poultry producing region in Hungary's agricultural heartland, and there is a farm housing 3000 ducks near the villages^ref.
• 4 more swans were found dead in the same location on Feb 13 and tested positive on Feb 21^{ref1, ref2}
• 2 more wild swans tested positive for H₅ in and around Nagybaracska town, where authorities already imposed a 3-km protection zone and a 10-km surveillance area
• on Mar 2 Hungary confirmed new cases of bird flu in a dead mallard found in Szentendre, a town north of Budapest. and a gull found in Szazhalombatta, 30 kilometres (20 miles) south of the capital, and in 2 dead swans  in Dunaszentbenedek (100 km south of Budapest) and Nagybaracska (where the previous week other dead swans had already tested positive for the H₅N₁ strain of avian influenza) in southern Hungary^ref
• another birds reported positive on 13 Mar 2006
• on Jun 4, HPAI H₅N₁ was found at 6 farm with > 3000 geese in Bacs-Kiskun province (2 in Bodoglar (28 000 and 15 000 birds, respectively); 3 in Moricgat (110, 120, 126 birds) and one in Szank (19 000 birds)) in southeast Hungary, with 3107 birds, 1600 which were affected and 807 who died. 300,000 birds, mainly ducks and geese, were culled. This area exports goose liver and contains significant duck farming ^{ref1, ref2}
• Romania^{ref1, ref2, ref3, ref4} : the last reported outbreak of HPAI in Romania was in 1942. Romania hopes to join EU in 2007. As of Jan 14, 2006, H₅N₁ has been recorded in 26 villages (laboratory confirmed only in 9)^{ref1, ref2} :
• 4 sites within Tulcea County, in the Danube delta (which is home to around 14,000 people, at a distance of 100 km from the border with Bulgaria, near the Black Sea) :
• Ceamurlia-de-Jos municipality, close to Golovita Lake, South Tulcea County. 3 ducks and 2 laying hens out of 36 birds died since late September 2005 in the backyard premises (100 birds : 58 laying hens and 42 ducks) of a 2-peasant family tested positive for H₅ (ELISA and agar gel immunodiffusion) at the Institute for Diagnostics and Animal Health in Bucharest on Oct 7 2005. On Oct 13 samples were sent to the Veterinary Laboratories Agency, based in Weybridge, Surrey, UK for a thorough analysis. The minister ordered culling of the remaining 64 birds and imposed quarantine for 3 km (2 miles) around the site and all domestic birds would be culled to prevent the disease from spreading in the environmentally sensitive delta, Europe's largest wetlands. Flutur also said hunting was banned in 8 counties across the delta. Romania's Danube delta and lakes in northern Bulgaria are popular with flocks of red-breasted geese from Siberia as well as white-fronted geese from Scandinavia, Poland, and Germany. It is believed they contracted the virus from migrating birds from Russia. Romania has also halted chicken and poultry imports from 15 countries, mostly Asia. Residents have been urged not to let their animals roam free. Officials have also restricted the movement of people in and out of Ceamurlia and banned the transport of animals. Medical teams are to administer flu vaccines for residents : some 3,400 people in the Danube Delta have already been vaccinated with numbers expected to reach 125,000 in the coming days. Ceamurlia is situated in the south of Tulcea County, about 50 km to the south of the county's capital, Tulcea (population: 92 000)^{ref1, ref2, ref3}. The Danube Delta is characterised by the plentiful population in an expanse of wetlands and a flyway for migrating birds. Such birds were suspected as vectors of West Nile virus into the region during the 1990's. Up to the morning of 13 Oct, a total of 4797 birds (4009 hens, 318 ducks, 238 geese and 232 turkey hens) from 72 backyard premises (out of a total of 420 backyard premises existing in Ceamurlia-de-Jos) had been killed and their cadavers destroyed by incineration. Culling and incineration procedures for domestic poultry are still in progress and will be completed as soon as possible : the country would cull around 45,000 birds. Hungary said on Sun Oct 9 it has banned the import of poultry meat, livestock and all related products from Romania. The special report "Wild birds and avian influenza" of FAO's Animal Production and Health Department includes a schematic major-flyways map of migratory birds^ref : from the map referenced above, it seems clear to me that, at least up until now, the virus has not been spread by migrating birds, since the direction of spread has been east-west, cutting across several north-south flyways and following the frontier between Russia and Kazakhstan westwards from the Mongolian border. Could there be a flourishing trade in poultry along the border? Initial tests for avian flu viruses by UK DEFRA were negative, but tests would continue for several days : the results of the tests were expected on Fri 14 Oct but it emerged that the samples have not even arrived at the Veterinary Laboratories Agency in Weybridge, Surrey, apparently due to customs/security procedures. The delivery occurred later in Fri 14 afternoon : on Sat 15 Oct British lab tests confirmed the H₅N₁ strain. All tests executed in Romania over the possible bird flu cases in the country have proved negative, but EC experts had detected the H₅ virus strain in 2 samples. An additional seropositive wild duck was identified. The outbreak in Ceamurlia-de-Jos was eradicated. A total of 18 626 domestic poultry were killed and their carcasses incinerated, and disinfection was carried out
• Maliuc district :
• Maliuc village, about 20 km east of the city of Tulcea and 40 km (25 miles) north of Ceamurlia de Jos where the 1st outbreak occurred : the Romanian agriculture ministry confirmed on Fri Oct 14 that 2 birds (a hen and a swan) had tested positive for the H₅ strain and birds are being culled as a precaution. Maliuc commune is situated in the center of Tulcea County, about 15 km east of the region's capital, the city of Tulcea^ref1,ref2. All 21 000 domestic birds in these 2 villages have been culled. 537 swans tested seropositive;
• Vulturu village : 46 hens and 2 turkey hens (backyard flock).
• C.A. Rosetti village, about 60 km east-north-east of Maliuc, 10 km away from the Ukrainian border, in southeastern Romania (about 60 km to the east of Maliuc). On Oct 18 a swan tested positive with bird flu antibodies
• Jurj Vasile village (information on its exact location will be appreciated). OIE news release of 17 Oct 2005. Samples from chickens, analyzed at the OIE Reference Laboratory, confirmed to contain Influenza A subtype H₅N₁.
• Smardan village, in north west Tulcea region : on Sat 8 Oct 2005, Ion Agafitei, the chief veterinarian, was cited telling reporters that 3 (unspecified, additional?) birds had tested positive for the virus. No further data followed. Quarantines had been imposed in the 2 villages and 5 others where suspicious bird deaths had occurred in recent days. Additional information referred to tests on several swans which had been found dead nearby, to be finalized in a couple of days. Samples from the dead ducks are also being tested for the detection of avian influenza virus (virus isolation test on embryonated eggs: HPAI should kill the chicken embryos in 3-4 days) at the Romanian laboratory. After 4 days, as of Sun 9 Oct 2005, this test has not given any positive result so far; however, a "2nd passage" in eggs is now being performed.
• Silistea village : there are also signals that hundreds of birds had died over the past few weeks, yet the deaths went unreported.
• Caraorman village : on Mon 14 Nov 2005 morning, the veterinary lab in Tulcea confirmed the presence of H₅N₁ virus in 4 birds that died several days ago. Caraorman, the village where in the 2nd week Nov 2005 a lot of domestic birds died, is in the heart of the Danube Delta, 13 miles away from Sulina city^ref. The village, which has no road access, would be quarantined and 2000 domestic birds would be slaughtered. In the villages Partizani, Caraorman and Crisan, in the past days, hundreds of birds have died. Near Sulina, 100 swans have been found dead^ref.
• 7 swans, found dead in Tulcea County, Sulina District, Musura bay, N-NE  zone; and 1 water hen (common moorhen, Gallinula chloropus?), found dead in Tulcea County, Caraorman District, Obretinul Mic Lake on 21 Nov 2005 tested positive for H₅^ref.
• Periprava village : a new case of the H₅ strain of bird flu has been detected in a duck and a chicken. The affected farm included 49 susceptible

hens, with 45 cases, 8 mortalities, and 41 culled; on Nov 28, authorities are going to start the slaughter of about 1500 birds^ref
• Agighiol village experienced an outbreak on Dec 5
• Crisan village experienced an outbreak on Dec 5
• Jurilovca village : rapid tests made on 6 hens led to suspicion of the presence of the bird flu virus on 9 Feb 2006^ref
• Salcioara village
• Sarinasuf village
• Constanta county, at the border with the Tulcea County :
• authorithies are conducting preventive, disinfection, and control measures in northern part after the dead body of a pelican was found on Wed 12 Oct night on a field between Mangalia and Albesti, but given the bird's advanced state of decomposition, no samples have been taken.
• a wild goose near the village of Vadu Oii (lat 44.18, long 28.65; close to the Danube river in Mihai Viteazu district, Constanta county^ref) and a swan next to the Razim lake (the biggest lake^ref in the delta near the Black Sea, which wild birds use to rest on their way to warmer climes) collected earlier in October 2005 tested positive for H₅ on Oct 30 2005. The areas will not be quarantined as the birds were found at least one mile from the nearest human settlement and no poultry will be culled. The areas are roughly 44 miles from each other. > 500 tests were done over the past 2 weeks on birds in the country's south-east and they all turned out negative for bird flu.
• Mereni village, Topraisar (Trpraisar) district (40 km north of the border with Bulgaria) : on Feb 17, rapid tests on 2 dead hens found in a courtyard led to suspicion of the presence of H₅ and all 20 hens from the courtyard were killed^ref. A wild pigeon found dead near an irrigation canal at a distance of 2 km from Mereni village. 2600 poultry have been culled in 110 backyard premises^ref. Topraisar Mayor Stelian Gheorghe was offering rations of bread, rice, sugar, oil and mineral water to more than 1300 families to help offset the loss of livelihood from the dead birds^ref.
• Aliman village : H₅ confirmed on Feb 14
• Ostrov village, near the border with Bulgaria : H₅ confirmed on Feb 14 (backyard premises with 27 hens; samples have been collected from 10 hens; 18 deaths, 9 culled)^ref
• Vlahii village, Aliman district, near the Danube River : H₅ confirmed on Feb 13 (backyard premises with 69 hens and 7 geese; samples have been collected from 5 hens : 61 deaths, 15 culled). 2500 birds would be culled^ref
• Tuzla locality : 37 birds (19 deaths and 18 culled) since 16 Feb 2006 (backyard premises with 30 hens and 7 geese)^ref
• Navodari locality : 72 birds (37 deaths and 35 culled) since 16 Feb 2006 (backyard premises with 71 hens and 1 pheasant)^ref
• Tupalu village, around 60 km (40 miles) north east of the small Black Sea resort of Navodari, where bird flu was confirmed on Sun 19 Feb 2006 : all birds in the yard involved had been culled; there were 600 households in Topalu, which have around 15 000 domestic birds^ref. All the 15,000 domestic birds in Topalu will be culled^ref
• Cernavoda village, situated about 80 km northwest of Constanza : on 14 Mar 2006, quarantine measures imposed following the discovery of dead wild birds there (Romanian TV channel Realitatea TV, morning news edition)
• Ion district / Corvin / Crangu village : 117 susceptible / 117 cases / 67 deaths / 50 destroyed since 27 Feb 2006
• Saligny district / Azizia village : 88 susceptible / 88 cases / 29 deaths / 59 destroyed since 27 Feb 2006
• Satu district, Satu Nou village : 99 susceptible / 99 cases / 56 deaths / 43 destroyed since 27 Feb 2006
2 babies aged 4 and 7 years who were on holiday at grandfathers' farm in Topraisar were admitted to Costanta hospital with bird-flu symptoms on Feb 10 but tested negative on Feb 14^ref
• Vaslui county in Eastern Romania (lat 46.60, long 28.07; some 100 km (60 miles) north of the Danube delta, close to the border with Moldova, in an area not in the immediate vicinity of a any villages or towns, but identified as in the the vicinity of the village of Falciu) : a sample coming from a heron found at a distance of about 700 m from Prut River, tested positive for bird flu anti-H₅ antibodies on Oct 21, 2005 : on Oct 27 the laboratory in UK confirmed the presence of the H₅N₁. Avibase lists 4 heron species in the checklist for Romania, so it is not clear in which species H₅N₁ virus was detected.
• Braila county^ref :
• Scarlatesti village, some 70 miles (113 km) from the delta and 170 km from the capital Bucharest : a turkey found dead on Nov 26 tested positive for H₅N₁ on Dec 9. The village, which has 1000 farmers and 50 houses, is isolated in an area of lakes, 3 km from the next village (Lat 44:58:00N (44.9667), Lon: 27:11:00E (27.1833)^ref). Scarlatesti has nearly 400 homesteads, with an estimated 15 000 fowl. No fewer than 249 test samples have been tested in Braila County since early October 2005. Local residents had slaughtered all their 11 883 poultry by 27 Nov 2005 and have received 2.8 billion leus (USD 93 300) in compensation from the government
• Dudescu village (situated about 3 km from Scarlatesti) : an outbreak reported on Dec 2
• Bumbacari village : an outbreak reported on Dec 2
• Ciocile village : H₅ discovered on Dec 3, 8000 birds culled
• Tataru village : 3 suspected bird flu cases in hens on Dec 12
• Chichinetu village^{ref1, ref2} : a suspected outbreak on Dec 19 that has yet to be confirmed. 2 different backyard premises, 500 m apart. Both premises are situated in a boundary area of the village, in the vicinity of the lake Chiobaiesti. There are 136 backyard premises in the village, including a total of 3350 fowl. The distance from the previous outbreak in Ciocile is 3.5 km. Veterinary and local authorities decided to apply a partial stamping-out, culling 329 poultry from 22 backyard premises, since the first cases appeared (14 Dec 2005). Disinfecting was performed, also the installing of "sanitary filters" at the entrance to the infected area. Quarantine, zoning and screening was also performed.
• Ciresu and Dudesti village : preliminary tests taken from domestic birds from outbreaks started on Jan 10 showed potential signs of the H₅ type on 11 Jan 2006^ref
• Zavoaia village : 62 susceptible / 6 cases / 6 deaths / 56 destroyed since 28  Feb 2006
• Buzau county west of the Danube delta, with a population of around 150 000, is some 100 km (60 miles) north of the capital
• Padina village : a domestic hen and 4 ducks tested positive for H₅ on Dec 11. Padina lies 10 km (6.2 miles) west of the village of Ciocile, where the disease was also detected earlier in December 2005
• Buzau village : a single bird on 27 Feb 2006
• several hens and turkeys from a small Gypsy (Roma) community, one km from the village of Braesti, about 130 km (80 miles) west of the Danube delta and about 150 km north east of the capital Bucharest on Dec 12
• H₅N₁ detected in a wild goose on Mar 3; nobody touched it^ref
• Ialomita county^ref :
• Marsilieni village : on Dec 18 dead chickens from 5 farms were confirmed to have carried the H₅ strain of bird flu
• Rovine village (Reviga district) ?
• Stelnica village (around 160km east of Bucharest, on a Danube river tributary [Lat: 44:25:03N (44.4174),  Lon: 27:50:49E (27.8469)]) : rapid tests on samples taken from hens raised suspicion of the H₅ type
• Traian village (100 km (60 miles) east of Bucharest) : 50 hens with suspected bird flu culled since Dec 19
• Albesti village (90 km east of Bucharest) : starting 27 Dec 2005, reported to the OIE on 4 Jan 2006, poultry were positive for the H₅ viru and were culled^ref
• Calarasi county :
• Stefan Voda village : on Dec 23, samples from domestic birds from one small farm tested positive for bird flu
• Borcea village : 37 susceptible / 2 cases / 2 deaths / 35 destroyed since 28 Feb 2006
• Unirea village : 51 susceptible / 51 cases / 7 deaths / 44 destroyed since 27 Feb 2006
• Dolj county :
• Cetatea village, 500 km (311 miles) west of the Danube deltas [44.10 N, 23.05 E^ref] : rapid tests made us suspect the presence of the H₅ strain of the virus in 3 hens found dead : 10 birds were culled
• Dambovita county :
• Catunu village, 80 km (50 miles) west of the capital : H₅N₁ detected in domestic birds on Mar 3, 2006^ref
• Morteni village : 26 deaths out of 26 susceptible since 27 Feb 2006
• Olt county
• Ilfov county
• Magurele village (Lat: 44:24:55N (44.4152) Lon: 26:03:04E (26.0512))^ref, about 50 miles southwest of Bucharest : bird-flu outbreak in poultry on Mar 22, 2006^ref
A new wave since May 2006 : in the commune of Balotesti, Vrancea County, but in other locations as well, even the local authorities opposed the quarantine measures^ref. 83 confirmed outbreaks on May 26^ref, 88 on May 29^ref :
• Brasov county^ref, central Romania : 16 confirmed (11 liquidated) and 11 suspected foci as May 22^ref. Outbreak in Codlea: chickens and turkeys in a commercial farm; the affected chickens, aged 32-35 days, showed clinical signs including anorexia, diarrhoea and cyanosis (skin, combs and wattles)^ref. Health authorities are on the hunt for several dozen tonnes of chicken products produced at Dakrom poultry farm where the deadly H₅N₁ strain of the flu was found^ref : authorities finished culling on May 22, when started to cull the birds at Pati Prod (another farm in Codlea, where there are 600 000 chickens. Culling was not started at chicken farm No. 4 from the same complex, where the tests were negative^ref. The experts have to incinerate about 600,000 chicken^ref. On Fri 13 May 2006 bird flu virus was active in 3 chicken plants and quarantined the town of Fagaras and other 8 villages as a result. These were the 1st cases of birdflu outbreaks in commercial chicken farms in Romania. The 53 outbreaks identified since October 2005 occurred on family farms only. The last such outbreak was officially closed in late April 2006. The 3 plants where the bird flu virus originated are Dracom Silva, Pati Prod, and Avi Prod, all located in Codlea town, Brasov County. The bird flu virus was identified only when one individual bought 500 chickens from Dracom Silva and resold them to other farmers. The chicken plants did not inform authorities of the unusual death rate of the poultry, Flutur said on Mon 15 May 2006. The farms sold live chickens to farmers in 5 counties, while hundreds of tons of processed meat made it to stores in 20 Romanian cities. Authorities said the meat poses no threat to health if cooked for a long time, but 220 tons of meat were taken out of store shelves and destroyed. Farmers will get compensation for their culled birds, but processing plants will receive them only if they complied with sanitary laws. The people responsible for spreading the virus through the selling of live virus-tainted chicken will be prosecuted by law. Authorities prevented from leaving the farms some one dozen people working there; they will be hospitalized, as none of them used safety gear. However, the farms also illegally employed people who will be difficult to track down, as they were not on the company's records. All 104 000 birds in the Dracom Silva plant will be culled, and sanitary authorities around the country, as well as store managers, are bound to search and destroy any chicken products originating in the Brasov County. The transportation, buying and selling of live birds was banned on all of Romania's territory for 2 weeks, starting Sat 13 May 2006. Hunting of birds is banned till 1 Aug 2006, as usual, but authorities enforced a ban on hunting mammals too in all areas where bird flu outbreaks were confirmed^ref. The H₅N₁ strain was confirmed late on Sun 21 May 2006 by the Weybridge Laboratory in U.K.^ref. The preliminary tests from Aviprom Codlea farm came out positive, however the authorities are waiting for confirmation from the laboratory in Bucharest. Over 4000 birds will also have to be culled. Following Districts 2 and 4, it is now the turn of another district to face the avian flu. In District 5, in a private household, avian flu suspicions appeared on 24 May, when a hen was found dead. The quick tests confirmed the H₅ virus and the authorities disinfected the area while the 6 persons living there, 3 adults and 3 children were given anti-viral drugs^ref
• Fagaras county :
• Covasna county : 1 confirmed (liquidated) focus^ref
• Vrancea county : 3 confirmed and 2 suspected foci^ref
• Bacau county : 3 confirmed foci^ref
• Buzau county : 1 confirmed (liquidated) and 2 suspected foci^ref
• Sibiu county : 1 confirmed (liquidated) and 1 suspected focus in Sibiu city^ref
• Valcea county : 4 suspected foci^ref
• Prahova county : 2 suspected foci^ref
• Neamt county : 1 suspected focus^ref
• Alba county : 1 suspected focus^ref
• Bucharest : 2 suspected foci^ref. after a series of preliminary tests revealed on Fri 19 May 2006 that some domestic poultry in the 2nd district, where there are more than 400 households that have some 4400 chickens, Bucharest might be carrying the H₅ bird flu virus, prompting authorities to quarantine a street in the Andronache neighborhood of Sector 4 and restrict access to other areas in Sector 2. The final tests confirmed the virus on 21 May 2006, and the authorities enforced the Level 1 quarantine measures, which are meant to isolate a 3rd of the households in sectors 2 and 4. Authorities quarantined at least one street in an eastern part of the capital on Sat 20 May 2006 and began culling birds and disinfecting streets in the 2 districts. Access was restricted to 65 streets in both districts, where about 2000 residents live, Videanu said. Meanwhile, the residents were given oseltamivir^{ref1, ref2}
• Gurgevo province [probably Bulgarian for the Romanian province Giurgiu^ref], just 40 km away from the northern Bulgarian border, near the village of Balbukata, some 800 birds were culled on Jun 8, 2006^ref
Outbreaks in Bacau, Beclean, Bolotesti, Brasov, Bucuresti, Buzau, Buzaului, Dumbravita, Neamt, Sibiu, Sita, Vistea and Vrancea: all poultry came from backyard premises in Brasov, Covasna and Vrancea counties and originally bought from SC Drakom Silva SRL and SC Pati Prod Co SRL in Codlea. They showed clinical signs immediately after their introduction into the premises^ref.
Between 13 May 2006 and 25 May 2006 there were 57 outbreaks in backyard poultry in 12 provinces including 23 in Prahova province. Other provinces included Alba Arges (2), Bacau (6), Brasov (11), Bucuresti (2), Buzau, Gorj (2), Ilfov, Mures, Valcea (3), Vrancea (3). The outbreaks involved 18 174 birds resulting in 3723 deaths^ref.
The report of Romania's Intelligence Service, or SRI, stating the bird-flu in Romania's chicken farms allegedly originated in imports from Hungary and Slovakia was inconclusive. The Slovak company Liaharensky Podnik, alleged to have sold tens of thousands of chicken, said it sold only a few hundred birds, more than 3 months ago, to Romania's Drakom Codlea, where the bird-flu virus outbreak originated. Romania's Verba Trans Brasov, which according to the SRI report sold tens of thousands of bird-flu contaminated turkey chicks imported from Hungary to other Romanian companies, said it actually bought chicken, not turkeys, and did not sell them but still has them alive and well on the farm : they bought in January 2006 from Hungary's Aviagen a total of 41 860 young chickens. They are 18 weeks old, and in 8 more weeks, they will start producing eggs^{ref1, ref2}
Clearly, the virus is present within the Danube Delta region in wild birds (swans, ducks) and domestic fowl (chickens, ducks). Official, first-hand updates will help in elucidating the picture.
• Zdenek Hubalek. An annotated checklist of pathogenic microorganisms associated with migratory birds. J Wildlife diseases 2004; 40: 639-659.
• FAO's (special report): Potential risk of Highly Pathogenic Avian Influenza (HPAI) spreading through wild water bird migration, 1 Sep 2005^ref.
Compensations for sacrificed poultry will range from ROL 60 000 to 80 000 (USD 2.00 to 2.67) per kg of live bird, depending on the damages incurred in each case. The total amount earmarked for compensation funding reaches ROL 10 billion (USD 334 286). Also in Mon Oct 10 meeting, the government decided to allocate another ROL 40 billion (USD 1 337 240) to the National Veterinary Authority for procurement of protection, disinfecting and bird flu testing equipment. All ship captains received written advisories against transporting birds and animals from Tulcea. Similar safety measures have also been taken at the Small Island of Braila County, which is on the list of places with a high risk of avian flu, given its opening to the Danube and the large number of migratory birds that take shelter here each year. The haemagglutinin (HA) and neuraminidase (NA) genes of the influenza A virus subtype H₅N₁ isolated from the duck are 100% identical to those of the virus from the chicken. Molecular phylogeny indicates that the NA gene of both viruses is identical to that of the H₅N₁HPAI virus strain A/turkey/Turkey/1/05 and therefore, as for the HA gene, is closely related to viruses detected recently in Central Asia. The haemagglutinating agents received (both samples 1 and 2) have been confirmed as influenza A subtype H₅N₁. Both viruses contain multiple basic amino acids at the cleavage site (PQGERRRKKRGLF) of the haemagglutinin gene and therefore contain a sequence consistent with HPAI. Molecular phylogeny indicates that the HA gene of samples 1 and 2 is most similar to that of A/grebe/Novosibirsk/05 (99.2% identity) isolated in July in oblast #39^ref and identity between samples 1 and 2 is 99.8%. The results indicate a direct relationship with viruses detected elsewhere in Romania, Turkey and Central Asia.
The newswires from Romania, describing the daily advance of the disease towards Bucharest, might evoke unpleasant reminiscences of the introduction in 1996 of another zoonotic virus, West Nile virus, which caused a major epidemic (352 recorded acute central-nervous-system infections, 17 fatalities). Though WNV, unlike avian influenza, is an arbovirus (Culex pipiens was incriminated as the vector), its initial introduction into south-eastern Romania and
Bucharest was ascribed to migratory birds. Surveillance activities included avian investigations; interestingly, only one of 12 Passeriformes sampled, an Erithacus rubecula, was found positive for neutralizing antibody to WN virus, while domestic fowl had a very high infection rate (see table 4 in^ref). The outbreak was confined to 14 districts in the lower Danube valley and Bucharest. The authors indicate that although the Danube Delta is home to only about 44 resident species of birds, millions of migratory birds, representing > 100 species, move through the region, many of them summering in northern Europe and Asia, including Siberia and Mongolia, returning southwards on their fall migration in August to October.
• a 81-year-old woman from the south-eastern town of Galati was admitted to hospital with symptoms similar to bird flu. Preliminary tests show no sign of avian influenza. It looks like she has bronchitis. Her condition is good and she has no fever^ref and tested negative on Jan 29^ref
On 10 Jan 2006, deaths of poultry were reported in Ciresu and Dudesti, Braila Department and H₅N₁ infection was confirmed. There are 7 active outbreaks: 3 villages in the Braila, 3 in Ialomita and one in Calarasi. Since the beginning of outbreaks, > 53,000 birds have died or been culled
Avian flu has been discovered in 40 villages since the first outbreak occurred in October 2005^ref. Romania could see human cases of bird flu, because its rural areas, where around 45% of the 22 million population live, lack proper water and sewerage systems^ref.
A 25-years old woman from Sita Buzaului, a village in central Romania where bird flu is suspected, showing bird flu-like symptoms was admitted to the contagious diseases hospital in Bucharest on May 16, 2006 : she tested negative on May 17^ref.
• Ukraine^ref : as of 4 Nov 2005 deaths of chickens have occurred in Myrolyubivka Village, Dnipropetrovsk Region. Turkeys and geese were not affected. On Dec 2 2005 1621 birds died suddenly in a half dozen villages in the Sovetsky, Nizhnegorsky and Dzhankoi districts in the Crimean peninsula : H₅ was confirmed in the villages of Nekrasovka and Sovetskoye in the Sovetsky district of the Crimea, and in the villages of Izobilnoye and Emelyanovka in the Nizhnegorsky district. The Crimea (officially Autonomous Republic of Crimea), is a peninsula and an autonomous republic of Ukraine^ref. It borders the Kherson region from the North; the rest of the border is the Black Sea in the South and West and the Sea of Azov in the East. Its area is 26 100 square km with a population of 2.0 million (2004). The capital is Simfeopol. The Azov Sea basins, and the Crimean territory, are situated on a main flyway of various species of migrating birds. Seropositive swans were detected in October 2005 in Romania, adjacent to the Ukrainian border. The 5 Crimean villages where bird flu-affected poultry have been found so far and areas within 3 km (1.9 miles) of them were placed under quarantine, and all poultry within them will be destroyed. It was the 1st time since the 1991 Soviet collapse that a state of emergency was enacted in Ukraine. The mapped trail of virus spread, from southern Siberia to the Balkans: in July 2005 -- Novosibirsk; in August 2005 -- Altai Territory, Chelyabinsk region, Kurgan Region, Novosibirsk region, Omsk region and Tiumen region; later in August 2005 -- Kalmykia; in October 2005 -- Romania, Turkey, Croatia. See BBC bird migration map^ref and OIE outbreaks map^ref. On 7 Dec 2005, the Russian news agency Interfax reported: "Poultry death registered in 4 more villages in Crimea. So far > 29 000 birds have been seized in house-to-house checks in villages sealed off by an exclusion zone. The government is paying for killed birds from $3 for a chicken to $18 for a turkey. Ukraine is also vaccinating the population in the affected area against seasonal flu to boost their immunity. The total number of poultry in the Autonomous Republic of Crimea as of 1 Nov 2005 was 10.4 million, comprising 6.3 million in the public sector and 4.1 million in the private sector^{ref1, ref2}. About 22 million domestic birds live in Crimea -- of 190 million throughout Ukraine. On 14 Dec 2005 a total of 54,000 domestic birds have been confiscated from residents of 3 Crimean regions where bird flu outbreaks have occurred. Compensations exceeded 680 000 hryvni (about USD 140 000). Veterinarians, doctors, and representatives of sanitary and epidemiological services visited 23 954 homes of farmers and inoculated 8977 people. 513 people, whose birds died of flu, are under medical surveillance. On Dec 12 domestic foul was found dead in 2 cities (Feodosia and the regional capital, Simferopol) and 19 villages (confirmed only in 9) on the Crimean peninsula. The Ukrainian samples arrived at 4pm on Tue 13 Dec 2005. Both Belarus, Ukraine's northern neighbour, and Bulgaria across the Black Sea slapped bans on imports, adding to measures put in place by Russia and Kazakhstan. Total : outbreaks in 25 village (laboratory confirmed in 11). On Jan 5, 2006 poultry were found dead on a farm in Solnechnoe village in Crimea. Mass fowl deaths were reported 3 farms in Crimea's Primorskoye village on 28 Dec 2005. Several days later the Vektor virology center based in Siberia confirmed the deadly H₅N₁ bird flu strain and on Jan 11 a total of 100,000 domestic fowl have been slaughtered : damage is estimated at about $400 000. 5 birds (one jay, one rook (Corvus frugilegus?), one wild duck and 2 pigeons (no Latin species names included)) found dead in one of Sevastopol kindergartens (a seagull) and a jay in KamyshovayaBay (3 crows), home to Russia's Black Sea Fleet and Ukraine's small navy tested positive forh bird flu on Jan 2006. Sebastopol is on the southwestern tip of the Autonomous Republic of Crimea, while the infected area is in the northern and northeastern parts of this peninsula. This is an additional circumstantial indication of the role wild birds might play in the spread of H5N1. Direct evidence is still pending. A question which remains unanswered is which avian species (singular/plural) is/are the (efficient) transmitter(s) of this particular virus strain in terms of distance and time. Ukraine's last follow-up report, No. 6, was sent to the OIE on 19 Jan 2006. It includes data on the recent confirmed and suspected outbreaks as well as updates on the laboratory results of previous outbreaks^ref. Specialised teams of sanitary workers have already destroyed well over 200,000 birds in Ukraine -- both privately held and at industrial plants^ref. Outbreaks have been suspected / confirmed in Beregove, Predmostnoye, Prymorske, Solar, Soniatchne and Zolotoie Pole villages in the Crimean Peninsula. The government veterinary services imposed a standstill order on all local poultry movements and instituted quarantine perimeters 3 km around infected villages with an additional 10-km buffer zone. AI outbreaks were reported in turkeys in Tsvitochne village, Bilohirsk District, and in Flower Village, Belogorsky, Crimea on 29 Jan 2006. A total of 137 wild birds have died in Alushta on 27 Jan and were confirmed as having AI. Deaths of 217 wild birds were also reported in Partenit on 29 Jan. As of 19 Jan 2006, > 200,000 poultry have died or been culled. Quarantine measures have been lifted in 16 villages in 6 districts. As of 25 Jan 2006, the total number of quarantined places is 9 (Feodosiya district (4), Kirovskiy district (4) and Dzhankoyskiy district (1)).

An H₅ avian-flu subtype was found in 24 villages in Crimea and the village of Tsevetochnoe was quarantined. The former Soviet republic of 47 million people has reported at least 33 outbreaks of avian flu since November 2005^ref. Ukraine's follow-up report No 9 on Highly Pathogenic Avian Influenza In Ukraine was sent to the OIE on 9 Feb 2006 said that no further suspected cases have been reported since 28 Jan 2006^ref. The outbreak of Newcastle disease in the farm "Staroverskiy" (Shevchenkovskiy district, Kharkiv region) has been notified to the OIE on 13 Feb 2006^ref. On 31 Jan 2006, avian influenza infection in 2 new localities in the Crimean peninsula was discovered. Around 140 wild birds were found dead due to avian influenza in town of Aloushta, and the presence of the virus was also confirmed in flocks in the village of Tsvetochnoe. The total number of quarantine posts on the territory of the affected districts is now one (post in Feodosiya district). Quarantine restrictions have been lifted in the following villages:
• Nekrasovka, Dmitrovka, Krasnoflotskoye, Sovetskoye, Chernozyomnoye, Prisivashnoye (Sovetskiy district);
• Izobilnoye, Akimovka, Yemelyanovka, Kirsanovka (Nizhnegorskiy district);
• Zavet-Leninskiy, Pushkino (Dzhankoyskiy district);
• Chernomorskoye, Khmelevo (Chernomorskiy district);
• Krepkoye (Krasnoperekopskiy district);
• Solnechnoye (Simferopolskiy district)^ref
3 or 4 pheasants and several parrots in 2 of the enclosures at Odessa zoo in southern Ukraine died of H₅ on Sat Feb 25, prompting officials to slap a quarantine on the facility's bird enclosures. There have been several previous outbreaks of HPAI H₅N₁ in zoos, including zoos in Thailand and Egypt. This is not surprising, in view of the exposure of such establishments to wild birds (in Thailand, feeding of carnivores with poultry carcasses was implicated). Culling is a control measure which might have to be excluded in certain cases, considering the need to preserve rare species^ref.
On Mon 12 Jun 2006 bird flu (H₅N₁?) was found at a village in Sumy region, near the border with Russia, after cases were noted on Sun 11 Jun 2006. Plans called for 7200 birds to be destroyed^ref. On June 2006 an outbreak in Sumy province in a village, Piski^ref, resulted in 335 cases (68 hens, 23 ducks and 244 geese), all of which died. There were 10 127 susceptible animals, and 7000 were destroyed
• Bulgaria : experts are testing samples from 3 dead birds found in different areas of the Pleven region, about 100 km from Bulgaria's Danube river border with Romania. A swan in the Danube River near the town of Vidin^ref, on its border with Romania, was found alive but died after showing symptoms of shaking and partial paralysis : it tested positive for H₅ on Fri Feb 3 2006. There is no sign of any strange behaviour or massive deaths by wild birds. Bulgaria, a relatively poor Black Sea country of 7.8 million, has banned the importation of poultry from its neighbours, forbidden the hunting of wild birds, told farmers to keep domestic fowl indoors and has stepped up surveillance of migratory birds in wetland areas^ref. Scores of birds died in the wetlands area, and about 30 domesticated ducks died at a farm near the Black Sea port of Varna on Sun Feb 5^ref. On orders from the state veterinary office, police began guarding the lakes of Shabla and Durankulak near the northeast border with Romania to prevent people from coming into contact with > 100,000 wild birds that spend the winter there. South of Europe's largest wetland area in the Danube delta, as well as the lakes, are situated along the Pontic migratory route, by which scientists believe birds travelling south from northern Russia may have brought the disease to southeast Europe. Hundreds of birds have died at the lakes since the start of 2006. Veterinarians have blamed that on a severe cold snap in which temperatures dropped to around -20°C (-4°F), but said they were stepping up measures anyway^ref. On Feb 5 Bulgarian authorities said it will supply all veterinary departments and the units of the Civil Defense across the country with Tamiflu to prevent the spread of bird flu^ref. On Feb 9, 2006 Bulgaria discovered 2 new cases of H₅ bird flu in dead swans in northeast Shabla (one in Lake Shabla near the northern border with Romania and the other near the Black Sea port town Varna) near its Black Sea coast^ref: Bulgarian police planned to shoot wild dogs and foxes which might spread around the remains of infected birds^ref. On Sat 11 Feb 2006, H₅N₁ infection was confirmed by VLA in a swan found dead on Jan 31 near Vidin, on Bulgaria's western Danube riverside^{ref1, ref2, ref3}. On Feb 13 a swan found dead in Bourgas, on Black Sea (some 3.5 km (2 miles) from a farm with 120 000 egg-laying hens), tested positive for H₅N₁. Preliminary tests have been started on at least 9 more dead swans collected at the dams of Tsonevo and Durankulak^ref, 2 ducks and a cormorant found dead across the country since last week^ref. Bulgaria produces around 9% of the foie gras consumed in Europe. On Feb 14, a dead pelican was found in the area near to Kozloduy nuclear power plant, situated in the upper part of the Bulgarian stretch of the Danube^ref.
• a man from the southern Bulgarian village of Preslavtsi, who had been in close contact with 2 dead ducks of his which are being tested by veterinary authorities for H₅N₁, was placed in an isolation facility by Bulgarian health authorities at a hospital in Haskovo and was tested for AIV infection, but he was not showing symptoms of the disease^ref
• on Feb 17 a woman was hospitalized in Bulgaria's second largest city of Plovdiv after showing bilateral pneumonia and respiratory deficiency. All necessary tests were immediately carried out, but despite initial negative results doctors will wait for their confirmation over samples sent to Sofia^ref.
• Serbia-Montenegro : at least 80 dead birds have been found in a farm in the Kosovo village of Vustria on Oct 14 2005. On Feb 28 a swan found dead in the region of Sombor^ref, close to the Croatian border, tested positive for H₅N₁^ref. On 4 Mar 2006, a dead swan (Cygnus olor) was found in the river Drina near Bacevci village at the border with Bosnia and Herzegovina; and the presence of avian influenza was confirmed. On Mar 8, 2006 3 swans from Backi Monostor and Bacevci (Bajina Basta) in the municipality of Sombor tested positive for H₅N₁ : a swan was found in the Veliki Backi canal^ref. On 9 Mar 2006 a swan tested positive for H₅N₁^ref. An outbreak in a rooster out of a flock of 23 chickens in Zlatiborski in the Bajina Basta area, south west of Belgrade, was reported on 15 Mar 2006^ref : it tested positive on Mar 25. The affected area has already been declared a risk zone within a 10 km (6 mile) radius, and veterinarians are monitoring all wild fowl and domestic poultry within it. Over 30 people in the area were under medical supervision as a precautionary measure^ref. On Fri Mar 17, 2006 3 children and a teenager from a bird flu affected area were in hospital after developing fever and flu-like symptoms^ref : on Mar 20 they were given the all-clear and discharged from hospital^ref.
• Greece : 30 migratory birds. about 20 turkeys started to die on 13 Oct 2005 in the islet of Oinousses [in Chios Prefecture, some 5 km from the region's main island, Chios, in the north-eastern Aegean sea, only 5 miles (8 km) at its closest point from western Turkey, where an outbreak of bird flu at a turkey farm, confirmed as H₅N₁, has brought a major cull]. H₅N₁was isolated from a dead turkey on Oct 17 2005, but final tests in Greece and UK on Oct 29 were negative. Preventive measures have been applied in Oinouses, Chios and Psara. In another newswire of 17 Oct 2005, the disease was reportedly suspected in 8 dead birds found in the northeastern Evros river delta (northeastern Greece) : 2 of the birds were found in Orestiada and one in Soufli. On Thu Oct 20 the EU Laboratory for Avian Influenza in Weybridge, UK reported that the 1st tests showed the Greek birds had not died from the H₅ bird flu virus. In neighbouring Albania, meanwhile, local television reported that thousands of Greek chickens were buried alive on the border after authorities refused to let them enter the country for fears that they could carry bird flu. On Feb 9, 2006, Greece tightened safety measures at poultry farms in the north of the country after 3 dead swans tested positive for H₅ bird flu in 3 separate areas (one in Kavala, 650 km north of Athens) around the Thermaikos Gulf south of the northern port city of Thessaloniki, in the northern Salonika region^ref : H₅N₁ was confirmed on Feb 12^{ref1, ref2}.
• on 30 Jan 2006, in the sea area of Paralia-Katerini [40°16' N, 22°35' E], Pieria district, Central Macedonia region, a fisherman found a dead swan and brought it at the seashore. The veterinary authorities collected the swan and sent it to the NRL immediately. The swan belongs to a "flock" [pod] that arrived some 20 days ago, probably from North due to bad weather conditions. No anatomopathological signs were observed. In addition, the Veterinary Authority of Pieria has been conducting an epizootic survey, since 9 Feb 2006 over the whole area of the Prefecture, far wider than the circle of 10 km around the point of collection. According to this survey, there are no findings of Avian Influenza in the area, while strict biosecurity measures have been applied to all poultry farms, especially to backyard flocks kept at the villages of the whole Prefecture.
• on 31 Jan 2006, in the area of the village of Stavros [40°40' N, 23°41' E], Thessaloniki district, Central Macedonia region, people informed the veterinary authorities about the presence of one swan found dead on the coast. The veterinary authorities collected the swan and sent it to the NRL immediately. The swan belongs to a "flock" [pod] that arrived some 20 days ago, probably from North due to bad weather conditions. No anatomopathological signs were observed. In addition, the Veterinary Authority of Thessaloniki has been applying an epizootic survey, since 9 Feb 2006, at the whole area of the Prefecture, far wider than the circle of 10 km around the point of collection. According to this survey, there are no findings of Avian Influenza in the area, while strict biosecurity measures have been applied to all poultry farms, especially to backyard flocks kept at the villages of the whole Prefecture.
• on 1 Feb 2006, in the area of the village of Nei Epivates [40°30' N, 22°54' E], Thessaloniki district, Central Macedonia region, people informed the veterinary authorities about the presence of one swan found dead on the coast. The veterinary authorities collected the swan and sent it to the NRL immediately
On 3 Feb 2006 in the northern part of the central Aegean island of Skyros (2900 inhabitants; longitude: 38°56' N; latitude: 24°33' E)^ref, Hellas district, Sterea region, people informed the veterinary authorities about the presence of one wild goose found dead. The veterinary authorities collected the wild goose and sent it to the NRL immediately^ref. The bird species is wild red-breasted goose (Branta ruficollis, which conservation organisation Bird Life International describes as "globally endangered" and Eurasian migrant). No anatomopathological signs were observed. In addition, the Veterinary Authority of Evia has been applying, since 10 Feb 2006, an epizootic survey and fully implementing all the measures stipulated in the EU Commission Decision 2006/86/EU throughout the whole territory of the Island. According to this survey, there are no findings of avian influenza in the area, while strict biosecurity measures have been applied to all backyard flocks kept in villages over the whole island. There are no commercial poultry farms on the island, but a 3-km zone around the area of the dead bird's discovery has been imposed regardless^{ref1, ref2}. A veterinary squad from the local prefecture vaccinated a number of municipal staff for house calls, and briefed citizens on the issue. Skyros has no major poultry farms. A Greek airman who found the goose at the island's airport on 2 Feb 2006 has already been tested, and has displayed no worrying signs. Bird hunting has already been banned on Skyros and the prefecture of Salonika, while owners of poultry in both areas have been ordered to shut their flocks indoors^ref
On Mon Feb 13, 2 people were quarantined in separate hospitals in the northern Greek port city of Thessaloniki as a precautionary measure pending results of tests for bird flu^ref. The first case involved a 15-year-old boy who had contact with a swan on Feb 3 and developed flu-like symptoms : he was released on Mon 13 Feb 2006 after twice testing negative^ref. The second case involved a 29-year-old hunter who killed 3 wild ducks a week ago : he was released from quarantine on Tue 14 Feb 2006, after he tested negative too^ref. A 19-year old hunter who touched wild ducks with hands on Feb 8 was admitted to Papanicolau hospital in Saloniki on Feb 13 with flu-like symptoms. A 78-years old female and a 65-years old farmer were admitted to hospital on Feb 15 after touching dead chickens^ref.
On Tue 14 Feb 2006 H₅ was isolated on 2 more dead swans in coastal areas of northern Greece. Protection zones have been created around the airport of Skyros, and 3 beaches near the northern city of Salonika, where the 1st dead birds were discovered. 2 more dead birds found on Skyros have been sent to an EU-certified laboratory in Salonika for tests^ref
On 17 Feb 2006, H₅ was suspected in 2 samples of swans found in wetlands in the Rodopi prefecture and in 1 swan in the Halkidiki prefecture^ref
On Feb 14, in a letter to Greek Orthodox church leaders, the Health Ministry asked priests to spread the word on precautions farmers should take to prevent infection by reading an advice bulletin to worshippers. It includes measures such as regular handwashing, a warning against approaching wild or free range birds, and a request that any dead poultry be reported immediately to the authorities^ref.
On Mar 3, 3 wild swans were confirmed with H₅N₁from a group sent for testing to London on Feb 24. Greece is awaiting test results on 8 more cases^ref.
On Tue Mar 7 Greece said 4 more cases of the deadly H₅N₁ strain of bird flu had been confirmed in 3 wild swans and 1 cormorant from a group sent for testing to London on February 28^ref
On Sat Mar 11, 2006, 4 more cases of the H₅N₁ were confirmed by VLA in swans found dead near its northern borders^ref
Poultry sales falled 95% since Sat 18 Feb 2006 to Feb 20^ref
• Macedonia : bird flu was suspected in the city of Bitola near the border with Greece, where another bird flu outbreak was under investigation. Macedonia officials planned to kill 10,000 chickens to contain the outbreak. On 19 Oct it was reported that the 450 deaths since Oct 14 were due to Newcastle disease virus and 5500 birds have been destroyed to date^ref : this disease is well known in the region, with Macedonia reporting 2 outbreaks in 2004 and 9 in 2003. Other countries in the region have had Newcastle recently. For example, in 2004, Greece and Albania reported one outbreak, Cyprus 2, and Russia had 12, while Serbia and Montenegro had 16 outbreaks in 2002. Some 1000 domestic chickens and turkeys found dead in the villages of Mogila and Germijan, about 200 km (120 miles) southwest of the capital Skopje, in mid-October 2005, tested negative for AI.
• Albania : 60 domestic chickens died in Cuke, close to the Butrint lagoon, a known resting ground for migratory birds, in the southern Sarande coastal county, Vlore state, about 30 miles from Greece since Feb 16. On Feb 23, 2006 one animal tested positive for H₅N₁ at the Veterinary Research Institute in Tirana and the result was made public on Mar 8: disinfection operations were under way^{ref1, ref2}. Albania planned to cull and bury nearly 2000 chickens in the southern Sarande area on Thu 9 Mar 2006. Villagers didn't eat poultry because they were observing Lent (for Orthodox Easter). Villagers were to get 700 leks (6.80 USD) for a grown chicken and 400 leks (3.90 USD) for a chick^ref. A new outbreak was reported in Vlore on 10 Mar 2006 : backyard chickens and turkeys were involved^ref. On Thu 23 Mar H₅N₁ was confirmed in 4 dead chickens in the Peze Helmes area (Latitude 41.2711, Longitude 19.7139^ref), some 10 km (6 miles) west of the capital Tirana : 600 chickens were culled. The bird flu scare has caused Albanian sales of chicken meat to fall by 80%. A truck with covered number plates dumped 80 chickens in a ditch on the road by the road to Albania's international airport on Wed Mar 22^ref.
• Slovenia : 24 wild birds since 16 Feb 2006. on Oct 7 tests ruled out bird flu virus in a suspected swan. In 4 notifications to the OIE between 16 Feb 2006 and 9 Mar 2006, Slovenia reported the identification of infection in 11 wild birds: 10 mute swans (Cygnus olor) and one Grey heron (Ardea cinerea). On Feb 12, a mute swan (Cygnus olor) found dead by a farmer in Koblerjev zaliv (< 10 km (6 miles) from the Austrian border) on river Drava, near Maribor city, Podravska region, and taken to his farm in St. Primoz where he informed the authorities, tested positive for H₅ and authorities established a 3 km (2 mile) protection zone around the area where the swan was found^ref. It tested positive for H₅N₁ on Feb 15^{ref1, ref2}. A further surveillance zone of 10 km crossed the Slovenian border and extended to the Austrian province of Styria. First official statements in Austria had said that the province of Carinthia, which also borders on Slovenia, would be affected by the measures. Deputy Carinthian Governor Martin Strutz later accused the Slovenian authorities of a 'chaotic information policy'. In Styria, an emergency plan was set up for the villages in question. Among other measures, there would be a ban on keeping poultry in the open air, and the animals would be examined by veterinarians^ref. Slovenia said it would test people who had handled the dead swans only if they showed signs of illness, and so far none of the 30 people who had been in contact with them had^ref. H₅N₁ was suspected in domestic poultry on a farm in Hotinja Vas (some 10 km (6 miles) south of Maribor and in the area where all wild birds infected with bird flu virus were found^ref) where 10 out of 14 hens died overnight on Mon Mar 20, 2006^{ref1, ref2}. 2 new outbreaks in Maribor are

reported : affected population: a northern pintail (Anas acuta) and a mute swan (Cygnus olor).
• Austria^ref : 29 birds :
• 4 of 21 (216?) swans and a duck found dead on 13 and 14 Feb 2006 in a reservoir in the district Graz-Umgebung^ref, near the southern city of Graz, were killed by the H₅N₁ bird flu strain according to tests performed at a veterinary laboratory in the lower Austrian town of Moedling, Styria province. H₅N₁ virus was discovered also in a wild duck found dead in Klosterneuburg^ref. Other suspicious bird deaths occurred in the Federal Provinces of Steiermark (district Hartberg), Niederosterreich (district Korneuburg), Vienna^ref
• an infected swan was detected in Slovenia, on the Austrian frontier, on 12 Feb 2006^ref. Laboratory tests on 2 other dead ducks found in the southern province of Styria were due on Mon Feb 20.
• on Sat Feb 18, 2 cases of deadly H₅N₁ bird flu virus near Vienna (a dead swan found in the Vienna suburb of Donaustadt and a dead duck found in nearby Lower Austria)^ref
• a swan was brought to "Noah's Ark" sanctuary in Graz (situated in southeast Austria, facing the Slovenian and Hungarian frontiers) from the area previously hit by the virus : the swan was kept in the same cage as 30 birds, violating regulations imposed after the 1st occurrence of the virus in Austria. When the swan died, all birds were culled ant tested : on Wed Feb 22, 2006 Austrian authorities found the H₅N₁ bird flu virus in 2 chickens and 3 ducks, the 1st case of domestic poultry carrying the H₅N₁ virus in the European Union, rather than in wild birds such as swans^ref
• 8 new cases -- 5 ducks, 1 chicken and 2 other unidentified birds -- were all found in security zones near the southern town of Graz^ref
On Mar 6, 2006, 3 cats among 170, 40 of which had been saliva-tested in the Noah's Ark, sanctuary in the city of Graz where the disease was detected in chickens tested positive for H₅N₁ in saliva in Styria state and were moved to a location where they will remain under observation^ref : a subsequent test of the 3 cats' faeces confirmed H₅N₁ in only one of the samples, in a very low concentration. A 3rd faeces test taken on Tue 7 Mar 2006 was negative for all of them^ref. If the affected cats come from the Graz animal sanctuary (contaminated by an introduced sick swan), the incident may have less significance than if the cats come from elsewhere. In the latter case, cats may have become sentinels of a widely spread infection among wild birds^ref. The fact that 3 cats tested positive in a 1st screening could indicate an infection in these cats. These findings, though, could also result from a contamination (e.g. bird feces) of the animals tested.

• Slovakia : on Feb 22, 2006, H₅ strain was reporteed in a wild hawk [species not specified] and a smew (a small Old World merganser, Mergus albellus^ref). The virus was discovered in 2 wild birds found dead on Feb 20, a white grebe in the capital city, Bratislava, and in a peregrine falcon found in Gabcikovo town at the border with Hungary and Austria^{ref1, ref2}. On Feb 25 the VLA avian influenza reference laboratory at Weybridge confirmed H₅N₁
• Czech Republic^ref: 14 birds in the region of South Bohemia, 7 confirmed as H₅N₁^ref
• the first dead swan (Cygnus olor), found on 20 Mar on the Vltava River in Hluboka nad Vltavou, south Bohemia, tested positive for H₅N₁ on 28 Mar 2006 at a UK-based EU reference laboratory^ref
• the second swan, found on Mar 25 on the Vltava River in Ceske Budejovice, around 150 kilometres (90 miles) south of Prague, 4 km from the first, tested positive for H₅ at the Czech National Reference Laboratory
• the third swan that was again found in Hluboka nad Vltavou about 300 m from the first, tested positive for H₅ on 30 Mar^ref
• the fourth swan has a virus type which is not yet known either.
• the fifth swan found dead in Bavorovice near Ceske Budejovice^ref on Sat Apr 1 tested positive for H₅
• a sixth swan near Ceske Budejovice on Apr 3
• the seventh swan died in Tyn nad Vltavou and tested positive for H₅ on Tue Apr 4^ref
• the eighth swan was found dead in Velka Cerna, about 5 km from the country's border with Austria and tested positive for H₅ on Apr 7^ref
• another 2 swans found on the right bank of the Vltava river, almost on the same spot where the 5th swan victim was found a week ago, in Bavorovice near the south Bohemian center Ceske Budejovice, tested positive for H₅ on Apr 4^ref
• the 11th case of bird flu, so far only confirmed as H₅, in a dead swan at on the Vltava river at Orlik, around 40 km south of Prague. A protection zone has been established at this new site^ref
• the 12th swan was reported from Ceske Budejovice on Apr 14 and tested positive for H₅^ref
• 2 dead swans in southern Moravia on 20 May 2006 tested positive for H₅, with a highly contagious form in one case^ref
A total of 1760 samples of wild birds found dead were tested between 1 Jan and 9 Apr 2006. 8 wild swans in Ceske Budejovice and one wild swan in Jindrichuv Hradec in Southern Bohemia were found to be infected with H₅N₁^ref.
Within the framework of the surveillance program, a total of 1259 samples of wild birds found dead were tested between 1 Jan and 25 Mar 2006, all with negative results^ref. According to the official notification of the Czech Republic to the OIE dated 29 Mar 2006, a total of 1259 samples of wild birds found dead were tested between 1 Jan and 25 Mar 2006 within the framework of the national surveillance program, all with negative results
• Croatia^ref (disease never reported before) : 10 dead starlings found near Zagreb on Oct 16 had been sent to a veterinary institute for testing. The starlings had no visible injuries, which prompted citizens to suspect bird flu, but they were often poisoned by farmers defending their crops. Starlings are not regular inhabitants of wetlands but are migratory and might have been in contact with infected birds. Croatia and Serbia lie on one of the main routes migratory birds from Europe use to go to Africa, where they could be in contact with infected birds. Initial tests of migratory wild fowl in Croatia were negative. About 1,500 migratory mute swans (Cygnus olor) arrived in Orahovica fish pond in Grudnjak village (45:34:45N, 17:56:44E), Zdenci municipality (a town of 1100, is located in Eastern central Croatia), Viroviticko-Podravska county^{ref1, ref2} on Oct 2005 and a fish farmer then found about 15 of them dead on 19 Oct : tests carried out by Croatian experts on samples from 6 of the birds led to the discovery of H₅ virus on Oct 21 2005 and on Oct 26 the laboratory in Weybridge confirmed H₅N₁. Conventional amino acid sequencing at the cleavage site of the haemagglutinin (HA) has revealed multi basic amino acid sequences of PQGERRRKKRGLF' which is consistent with HPAI. Molecular phylogeny based on a short fragment (300 base pairs) of HA1 indicates that the HA gene of all the 4 samples has a 99.7% identity with A/Great Black Headed Gull/Qinqhai/2/05, 99.3% identity with the Turkish virus and 99.1% identity with the Romanian virus. As of Nov 7, > 35 mute swans (Cygnus olor) have been found dead in Zdenci Municipality, Viroviticko-Podravska County (19 Oct 2005); Zdenci Nature Park (21 Oct 2005) and surroundings (24 Oct 2005); Nasice (22 Oct 2005); Baranjsko Petrovo Selo Village; and near Slavonski Brod City (27 Oct 2005), and the presence of HPAI H₅N₁ virus was confirmed in some cases. The Croatian agriculture ministry banned hunting of wild fowl and transport of poultry and told farmers to keep poultry indoors. It also banned the slaughter and sale of poultry in an area of 20 km (13 miles) around the fish pond. The European Commission is preparing a decision to ban the import of live poultry and poultry products from Croatia which will be adopted by urgent procedure on Mon 24 Oct 2005^ref. Croatian authorities culled 17,000 poultry around the Grudnjak fish pond over the weekend to prevent the virus from spreading. Another 10,000 poultry were killed around another pond in Ribnjak 1905 village, Nasice municipality (45:29:07N, 18:05:52E), Osjecko-baranjska county, where 15 more wild swans out of 244 died of bird flu between 22 and 24 Oct 2005 : on 24 Oct 2005 2 were found to be positive for avian influenza virus subtype H₅. On 23 October, in the same location, cloacal swabs were taken from 7 additional dead swans and from 4 hunted wild birds (3 shorebirds and 1 cormorant). Laboratory testing of these samples is ongoing. Avibase lists 3 swan species in the wild bird checklist for Croatia, so it is not clear in which species H₅N₁ virus was detected. A swan ringed as healthy in Hungary was shot down in the area where 8 swans had already tested positive for H₅N₁ strain : on 2 Nov 2005 it tested positive for H₅N₁ HPAI. Hungary had reported no bird flu cases at that date. The ban on keeping poultry in the open would be lifted on Fri 11 Nov, on condition poultry was kept in enclosed spaces. However, the government's order on keeping poultry in enclosed spaces will remain in force within 20 km of the fish farm in Nasice and the fish farm Grudnjak in the village of Zdenci, where the bird flu virus was found on Oct. 21^ref. Since 8 Feb 2006, some 35 swans were found dead in the capital, near Karlovac, at Lake Jarun, and near Sisak in the Zagreb area : at least 8 tested positive for H₅N₁^ref. H₅N₁ was confirmed on 20 Feb 2006 in a wild swan found on Ciovo Island. A 3-km area around where the swan had been found has been quarantined. Croatia said on Sat 25 Feb 2006 that it had found its 2nd case this week of avian flu in swans. The H₅ virus was isolated from a swan found dead near the coastal town of Trogir^ref in the southern Adriatic (43.53 N, 16.25 E, within Split-Dalmacija) near the sparsely populated island of Ciovo, where the lethal H₅N₁ strain of the virus was reported in a dead swan earlier the same week. Final typing is anticipated. On 14 Mar 2006, several samples from on > 30 seagulls taken randomly between 28 Feb and 3 Mar 2006 in the town of Pantana came back positive for the H₅N₁ strain^ref. On Apr 7 a swan found dead at the construction site of the new University Hospital, near  the shores of the Sava River in southeast Zagreb on Apr 2 tested positive for the H₅ strain of bird flu virus^ref: H₅N₁ was confirmed on Apr 10^ref.
• Bosnia Herzegovina : on Feb 20 Bosnia banned hunting of wild fowl, ordered all poultry to be kept indoors and banned imports of live birds and poultry products from Slovenia, Italy, Greece and Bulgaria. On Feb 20, 2006, Bosnia reported its 1st suspected case of AI in 2 sick swans (out of about 150 arrived around 11 Feb 2006 on the location of Plivsko lake) reported to have shown strange behaviour collected on Feb 16 in the village Plivsko jezero, Canton of Srednjobosanski (44.34694° N, 17.18855° E16), near Jajce along Pliva river (44.34694°, 17.18855°)^{ref1, ref2}, and on Feb 25 the VLA avian influenza reference laboratory at Weybridge confirmed H₅N₁. A total of 4420 poultry in 12 villages within 3 km of the lake have been culled. Every year, only one flock of swans were coming to Plivsko lake during bird migrations^{ref1, ref2}. 15 swans were destroyed. By 22 Feb 2006, all 2872 domestic poultry present within a 3 km radius around Plivsko Lake, where the positive swans were found, were killed and disposed of in a safe manner. From 2 to 5 Mar 2006, intensive sampling was carried out in the surveillance zone (10 km radius around Plivsko lake), during which 1214 samples were obtained from the domestic poultry population (blood samples and cloacal swabs); all the samples gave negative results. There have been no new cases, and all animals tested in the surveillance zone have given negative results. From 22 Mar 2006, all the protection measures applied in the area of the outbreak will be lifted.
• Lithuania : an Indian sailor who died in the Lithuanian port of Klaipeda may have been infected with bird flu. A member of the crew of the ship M.V. Ocean Wind died in Klaipeda. The suspected cause of death is bird flu. The sailor, who was the ship's cook, fell ill on Sat 4 Feb 2006. He died in a medical emergency vehicle on Mon 6 Feb 2006. A preliminary autopsy will be conducted on the 62-year-old sailor's body in Klaipeda, with a more thorough analysis to be undertaken in the capital, Vilnius, within 48 hours. The final results of the autopsy are expected in a few days. The Ocean Wind arrived in Lithuania from Germany on 17 Jan 2006. The basis for considering avian influenza virus infection as a possible cause of death after a 48 hour illness of an Indian crew member of a ship which arrived in a Lithuanian port from Germany on 17 Jan 2006 is entirely unclear. Perhaps the ship had been supplied with avian influenza virus-contaminated chicken carcasses somewhere en route to Germany and Klaipeda, and the sailor, who was a cook, handled a contaminated carcass?^ref
• Poland said all poultry must be kept indoors from Mon 17 Oct 2005 to keep it away from migratory wild birds. Suspected mortality was also reported on Wed 15 Feb 2006 from Poland (Gdansk), where 3 dead swans were found on a Baltic beach in the northern city of Krynica Morska and forwarded to the laboratory. Preliminary tests showed no signs of bird flu.
• on 5 Mar 2006 the 1st case of H₅ influenza virus detected in 2 dead swans found in Bydgoszcz^ref, Bydgoski, in the city of Torun (Turun) in the middle of Poland, about 160 km northwest of Warsaw^ref. The dead birds were found in the city water sports club area near the Vistula (Wisla) river. Authorities have established a high risk area of 3 km (2 miles) around the outbreak and a surveillance zone of 10 km. Restrictions have also been placed on the 6 poultry farms and 4 processing plants in the region : on 6 Mar the 2 swans tested positive for H₅N₁^ref
• on Sat 11 Mar the H₅ bird flu virus has been diagnosed in a dead swan found near a water-pumping station in the pumping station of Kostrzyn town^ref on the Odra river, at the edge of the Mouth of the Warta National Park, one of Europe's largest wetland nesting areas of migratory waterfowl, near the German border. Emergency procedures have been put into effect, with a restricted 3-km (2 mile) area under special surveillance as well as a 10-km endangered zone, which overlaps into Germany^ref. Poland official update of 13 Mar 2006, wild swan (specied not specified) and Mergus merganser^ref.
• Grudziadz (53°26' 18°26') in wild swans
• Gorzowski (52°35'26" N by 14°40'37" E) : 1 swan
• Torunski (30°00'20" N by 18°35'41" E) : 112 swans were captured and held in a cage as they were suspected of being infected. Because of the threat of spread, it was decided to destroy all swans suspected of being infected; the swans that were found not to be infected were released.
• Bydgoski (53°07' N by 18°03'24"E) : 1 swan
• Switzerland : 32 birds with H₅, only 9 of them (2 tufted ducks (Aythya fuligula), one common coot (Fulica atra), one goosander (Mergus merganser), 2 common pochards (Aythya ferina), one little grebe (Tachybaptus ruficollis) and 2 ducks (Anatidae, species not determined) positive for H₅N₁^ref. 3 dead swans found in central cantons (states) of Aargau, Solothurn and Schwyz on Feb 15 tested negative for the avian influenza virus by the reference laboratory in Zurich on Feb 17. About 600 swans die of normal causes every year in Switzerland, 300 of which are normally noted by the authorities. Heightened surveillance measures because of the threat of bird flu could be leading to a higher count of swans that died of normal causes than usual^ref. Switzerland ordered a nationwide poultry lock-up^ref. None of the 87 birds found dead in Switzerland over the past few weeks have tested positive for the virus^ref. On Feb 26 Switzerland said a duck found dead in the heart of Geneva, near the city's famous jet d'eau fountain, had H₅ virus. On Mar 1 Swiss reported a second case of bird flu in a dead swan found close to the town of Kreuzlingen at the northwestern corner of Lake Constance -- also known as Bodensee -- where 2 wild ducks have tested positive on the German side, although further tests were needed to confirm it was the H₅N₁ strain^{ref1, ref2}. On Mar 3, the H₅ virus was found in 2 dead ducks in Geneva, and in a duck in Ramsen village and a common European coot^ref in Stein, 2 places in the canton (state) of Schaffhausen near the German border^ref. Switzerland official update of 14 Mar 2006, tufted duck Fuligule morillon  and common coot Fulica atra^ref. On Apr 1 2006, a common pochard duck (Aythya ferina) found in Steckborn, Thurgau^ref, on Lake Constance tested positive. The results from about 12 bird flu samples are awaiting processing in London : it is expected that H₅N₁ will also be found in these samples, since none of them was negative for H₅. The reference laboratory in Zurich has revealed the infection in another pochard duck found in Steckborn^ref. The outdoor ban on poultry - the second in 12 months - introduced on Feb 20, 2006, will be lifted as of May 1, thanks to the reduced risk of bird flu : the last remaining surveillance zone in the country, around Lake Constance, would probably be lifted before next week^ref.
• Italy^ref [gene sequence of HA isolate] : on Oct 21, 2005 a young male of mallard (Anas platyrhynchos) aged around 1 year was killed by a hunter in an area located in the municipality of Mirandola, province of Modena^ref, in Emilia-Romagna Region.[Lat: 4:53:16N (44.8878), Lon: 11:04:03E (11.0674), about 45 km north of the city Modena] and on Nov 9 a cloacal swab tested positive for LPAI H₅N₁ virus at the National Reference Laboratory for Avian Influenza in Legnaro (Padova, Italy) by haemagglutination inhibition test, neuraminidase inhibition test, and genetic analysis. The amino acids sequence deduced from the cleavage site of the haemagglutinin molecule (PQRETRG) is typical of low pathogenicity avian influenza viruses (LPAI). Therefore it is a completely different pathotype than the Asiatic highly pathogenic (HPAI) H₅N₁ viruses. The Italian H₅N₁ represents a different virus, not related genetically to the aggressive Asiatic H₅N₁. This has been demonstrated by the analysis of the HA gene. The preliminary results indicate that the Italian virus is genetically related to other LPAI viruses commonly isolated in wild birds in Europe. The HA gene of the isolate correlated with the following LPAI strains sequences deposited in international databases: A/mallard/NL/3/99(H₅N₂); A/mallard/Sweden/7/02(H₅N₂); A/mallard/DK/64650/03(H₅N₇). > 1000 samples collected from wild waterfowl in Italy have previously been tested with negative results for H₅N₁ HPAI. There were some 60,000 hunters in the region of Veneto surrounding Padua with 10,000 specialising in duck hunting around Padua, Venice and Rovigo. Probably the bird was not migratory. It was probably born in Italy, due to its young age. The virus could be also of local origin too. This is the 1st time in 13 years that an Italian researcher has found an H₅N₁ virus in Italian wild birds. The discovery is good news, because the virus has a low pathogenicity and can boost the immune system of the birds, helping them to resist the Asian strain.

A 28-years old Chinese woman coming back to Turin after a visit to her relatives in China was admitted to hospital with flu-like symptoms on Feb 9 but tested negative.
On Feb 11, 2006, 22 wild mute swans (Cygnus olor) (20 found dead) from Southern Italy (believed to have been returning to Europe from Russia) were tested by the FAO/OIE Reference lab at Padua. 7 of them have been found positive H₅N₁^{ref1, ref2}. In total 19 wild birds tested positive :
• 6 swans in Puglia
• 1 from 'Saline e dune di Torre Columena' oasis, Manduria village, Taranto province (Puglia/Apulia region), found dead on 5 Feb, confirmed positive H₅N₁ on Feb 11^ref. Oseltamivir was immediately distributed to drug stores.
• 1 from Ugento village in Lecce province (Puglia/Apulia region) was confirmed on late Feb 12
• 1 from Torre S. Giovanni village in Lecce province found dead on Feb 7, confirmed ?^ref
• 1 from Rodi Garganico village in Foggia province was confirmed positive H₅N₁ on Feb 14
• 1 from "Cesine di Vernole" oasis, Lecce province, confirmed positive H₅N₁ on Feb 14^ref
• 1 from Giovinazzo village in Bari province, confirmed positive H₅N₁ on Feb 16^ref
• 2 swans in Calabria
• 1 from Pizzo Calabro, Vibo Valentia province (Calabria region) : found sick on Angitola lake on Feb 7, died at a veterinary centre in Cosenza, confirmed positive H₅N₁ on Feb 11^ref
• 10 birds from Sicily region (out of 14 H₅ cases)
• 8 swans
• 1 from Taormina village, Messina province : a swarm of 18 royal swans arrived on Feb 3 at the end of Niceto river : 2 swans were found died on Feb 11, a third on Feb 12 near lake Marinello in Tindari 1 swan was confirmed positive H₅N₁ on Feb 11. A colomba was found dead on Feb 12 in via Como, Vittoria village. 5 more swans were detected on Feb 11 : 2 swans, of which 1 very sick, were found at Oliveri, the remaining 2 in Ganzirri lake, and the last in province
• 3 from Catania province :
• 2 from Giarre village (near Riposto), found dead on Feb 9, confirmed on Feb 11^ref
• 1 from Mascali village, found dead on Feb 9, confirmed on Feb 11^ref
• 4 swans found dead in Mineo village, Catania province, tested positive for H₅N₁ on Feb 19^ref
• 1 from Marina di Melilli village, Syracuse province, found dead on Feb 2, tested positive for H₅N₁ on Feb 11^ref
• 2 found dead near Barcellona Pozzo Di Gotto village, Ragusa province, on Feb 9^ref : 6 other sick swans were culled
• a sultan (Porphyrio porphyrio) and a buzzard (Buteo buteo) which had contacted with them at the recovery centre in Catania village tested positive for H₅N₁ : other birds and a monkey at the center were tested^ref
• Umbria : a royal swan found dead on Feb 13 in Cerreto village, Panicale municipality, near Trasimeno lake, Perugia province, tested positive for H₅N₁ on Feb 19^ref
The other 16 swans from Sicily (Ragusa, Catania, Messina and Syracuse), Puglia (Taranto province) and Calabria (Vibo Valentia) are H₅, not yet further defined. The Ministry of Health has imposed animal movement restrictions for 21 days around the location (in Italy, Veterinary Services are located in the Ministry of Health). Emergency measures introduced by Italy include the establishment of a high-risk area (3-km-2 mile protection zone) around each of the outbreaks and a surrounding surveillance zone of 10 km, the European Commission said. Poultry in the zones will be kept indoors and only allowed to be transported to slaughterhouses. Italy has an historical position re HPAI : in 1878,  the disease was identified there for the first time and obtained -- for many consecutive years -- the name "fowl plague". However, until 1996 "fowl plague" (a name replaced, during the last decade of the previous century by "highly pathogenic avian influenza") was not regarded as a zoonosis.
2 policemen who came in contact with the dead birds in Giarre, near Catania, are under observation at Padua^ref. 2 trucks filled with migratory pigeons from Malta were intercepted in Giovino village, Lido, Catanzaro on Feb 11 and backed.
Another swan in Congiunti village, Collecorvino, Pescara province (Abruzzo) was collected by woman but tested negative for bird flu and positive for hemorrhagic enteritis on Feb 12, 2006. The same day 3 domestic ducks were found dead (since 4-5 days) on a river in Adria, 3 pigeons were found dead in Loano, Savona province (Liguria), a duck in Manfredonia and a real german in Cerignola, Foggia province (Puglia), were found dead. A duck and 2 blackbirds dead respectively in Villa Borghese lake and via Casilina in Rome. A 18-month old baby from a family in Corigliano was admitted at hospital in Crotone shortly after a domestic chicken died : he had encephalitis, not related to bird flu. A cormoran and an airone found dead in Orbetello lacuna tested negative^ref. On Feb 13 an airone was found dead along road 534 in Castrovillari, Cosenza village. A goose wad found dead at Telese lake, Benevento province. A sasselllo thrush was found dead at a house in via Alghero in Ascoli Piceno. 2 ducks were found dead in Altamura, Bari. A dead swan was found dead at the end of Petrace river, Gioia Tauro. A swan was found dead at Piazza S. Mauro lake in Nocera Inferiore, while a dead crow was found at Pontecagnano, Salerno. A dead and a sick swan were found in Montecotugno dam, Senise, Potenza. A pigeon and a hen were found dead in backyards at Guardavalle and Isca sullo Jonio, respectively. 5 more royal swans were found dead in Apulia. A swan and a sea-gull were found dead at Lugana di Sirmione, Brescia. 3 tortoises found dead in Pesaro tested negative, while results on a wild airone found dead on Feb 11 between Montefelcino and Isola del Piano, Pesaro, are pending^ref.
On Feb 14 > 80,000 chickens (20,000 and 70 in 2 plants in Syracuse; 60,000 at a plant in Cirò Marina, Crotone province), 7,000 eggs (at a plant in Cetraro, Cosenza province) and a stockpiling plant were sequestered in Calabria and Sicily^ref. In the Cosenza province, in the town of Rende, Coda di Volpe, a chicken and a dove have been found killed by wild dogs. In Diamante, Cammarotea, 10 bodies of chickens have been found^ref.
On Feb 15 a very sick swan was found in Locri, Calabria. A swan found at Fontanarossa airport (Catania province) tested negative^ref
Coldiretti, a farmers' group, showed that despite bans Chinese chicken were shown at Fieragricola (the main national agriculture exposure) in Verona on Feb 12. The free phone number 1500 was activated on Feb 13 2006 (since 9 a.m. to 8 p.m., Mon-Fri). Coldiretti said the sale of chicken meat had dropped by about 70% and 30,000 workers have been laid off in the poultry industry since bird flu was first detected on home soil : the spread could cause serious damage to a business worth 3.5 million euros (4.16 million dollars) and which employs 180,000 people. Poultry remained on the menu in the Athletes' Villages at the Turin Olympics, where organisers said the consumption of chicken and other poultry posed no health risk.
The European Union is against national regulations which impose the obligation of indicating on labels the origin of poultry and its derivatives, and has asked Italian Authorities to provide an explanation by February 15, since it holds that these regulations are not in line with community legislation. The announcement was made by Coldiretti, which considers "the observations by Brussels absurd and to immediately reject, especially after the discovery of the first cases of avian flu in wild birds. In the community statement, there are even the words that 'no element indicates that Italian consumers would be in error without the presence of the origin indications on poultry' while it is clear that origin labelling is an element of transparency which guarantees the traceability of products, greater efficiency of control and the freedom to choose by consumers. The 'Made in Italy' label has been obligatory in Italy since October 17, 2005^ref
Several months ago, Milan's health inspectors noticed that all of the Chinese restaurants in Milan bought their poultry from a single distributor. When they conducted a surprise raid at the warehouse of Euro Food International near the Piazza Morselli in Milan in March 2006, they discovered 3 million packages of meat from China^ref.
• Germany^{ref1, ref2} (last outbreak in May 2003) : 339 wild birds, 3 domestic cats and 1 stone marten have tested positive for avian influenza H₅N₁ Asia so far. Antibodies against an (hitherto undefined) AI were found on 25 Oct 2005 in 2 dead migratory geese at a lake in Neuwied in hineland-Palatinate State^ref, although the bodies of another 23 geese found at the same location did not contain any traces. While further tests should show whether that is H₅N₁ strain, the EU banned all imports of live wild birds to the block. The ban doesn't affect imports of < 6 pet birds by individuals, and only if they have been in quarantine or vaccinated against bird flu. On Feb 3, 2006, the German government ordered farmers to keep their poultry indoors beginning 1 Mar 2006 to help counter the threat of avian influenza^ref. In 2006 134 birds tested positive in 5 states :
• Mecklenburg-Vorpommern (Mecklenburg-Western Pomerania) state (total : 200 wild birds, including 165 from the island of Ruegen; 7 counties and towns affected^ref) : 4 swans and 1 goshawk were found dead on 8 Feb 2006 in 2 locations in the north of the island of Rugen in the Baltic sea. On Feb 14, AIV H₅N₁ has been diagnosed in 2 of the swans (a mute swan (Cygnus olor) and a whooper swan (Cygnus cygnus), both found in the countryside near the village of Wiek^ref) and a goshawk (Accipiter gentilis, found near the village of Dranske^ref) by NRL Friedrich-Loeffler-Institut and confirmed by CRL Weybridge, UK^{ref1, ref2} : some 100 dead swans had been spotted in the affected area^ref. German experts were examining 40 further dead swans found in near the first cases^ref. On Feb 17 10 more birds tested positive for H₅N₁ : 3 swans [probably mute swan, Cygnus olor], 6 whooper swans [Cygnus cygnus] and a goose [species requested]^ref : one of the latest birds to test positive for H₅N₁ carried a ring that was attached in 2005 in Latvia. The mute swan is a common temperate Eurasian species, often semi-domesticated; descendants of domestic flocks are naturalized in the USA and elsewhere^ref : this species is a sporadic migrant to northern Israel. No one has ever tried to study or understand during which years and what ecological pressures (at the summer grounds) force the mute swans to come as far south as Israel. Diagnostic investigation of carcasses of > 200 wild birds by real time RT PCRs specifically detecting avian influenza virus subtype H₅N₁ revealed highly positive results in, so far, 59 samples from several species, including whooper (Cygnus cygnus) and mute swans (Cygnus olor), Canada geese (Branta canadensis), tufted ducks (Aythya fuligula) and a hawk (Accipiter gentilis). Excessive viral loads indicated highly acute systemic infection. Sequencing of the HA proteolytical cleavage site showed a polybasic pattern (SPQGERRRKKR*GLF) indicative of highly pathogenic properties. Limited phylogenetic analysis of a 600 nt fragment of the HA gene revealed closest relationship with recent isolates from Romania, and, more distantly, with sequences from whooper swans of Lake Erkhul, Mongolia. All positive cases are restricted to the island of Ruegen, where large numbers of migratory birds are wintering. Monitoring activities of wild birds in surrounding areas have been increased in order to detect any spreading tendencies. Protection and surveillance zones targeting poultry holdings have been immediately implemented according to EU legislation. No outbreaks have been observed in poultry^ref. On Feb 21 another 22 cases of bird flu on the northern island of Ruegen were confirmed and another 7 on Feb 23, bringing the total to 110^{ref1, ref2}. A duck from a farm with 106 other birds which had not been scheduled for precautionary culling on the island, and that was suspected of having bird flu, however, tested negative for the H₅N₁ strain on Feb 23, 2006^ref. A domestic cat died near a docked ferry in Rugen island near the place of the 1st bird flu cases tested positive for H₅N₁ on Feb 28 at the Friedrich Loeffler Institute on Riems, another north German island : the cat's owner noticed the animal behaving strangely and informed local officials when it died the following day. The cat is believed to have eaten an infected bird^{ref1, ref2, ref3, ref4}. On Mar 8, 2006, Germany's Federal Research Institute for Animal Health confirmed the H₅N₁ virus in 2 more cats on the northern island of Ruegen. The cats came from Schaprode in the west of the island, close to where the first case of bird flu in a cat was reported. The German government has ordered cat owners in areas affected by bird flu to keep their pets indoors^ref. A stone marten found very sick in the same heavily affected area of Ruegen island, near Schaprode, as 3 dead domestic cats, was caught alive and later put down and tested positive for H₅N₁ on Mar 9, 2006 : as with the cats found on Ruegen island, the marten is presumed to have acquired its infection after feeding on an infected bird^{ref1, ref2}
• Schleswig-Holstein state (13 wild birds; 4 counties affected^ref), which neighbors Mecklenburg-Western Pomerania on the west :
• 2 wild ducks tested positive for H₅N₁ on Feb 24, 2006^ref.
• Rendsburg-Eckernfoerde district : 3 wild geese in Molfsee municipality on 24 Apr 2006; a crested grebe on 2 May 2006
• Ploen district : 1 graylag goose in Boesdorf municipality on 25 Apr 2006^ref
• Baden-Wuerttemberg state (18 wild birds; 5 counties affected, focus at the Bodensee^ref) : 2 ducks tested positive for H₅N₁ on Feb 25, 2006. A wild duck found  on Feb 15 at Lake Constance at the town of Uberlingen – the body of water which forms the German-Swiss-Austrian border in the northeast - was found to have the virus^ref.

Brandenburg state (19 wild birds ; 5 counties affected^ref) : on Sat Feb 25 2 wild birds (a swan and a wild duck (Fulica atra)) on the edge of Schwedt, northeast of Berlin and close to the border with Poland had tested positive for the H₅N₁ strain of bird flu, the first cases in that part of Germany^{ref1, ref2}. On 11 Apr 2006 a dead wild goose in the Dahme-Spreewald administrative area^ref tested positive for H₅N₁. On Apr 26 a white stork with H₅N₁ was found near Letschin^ref in the administrative district of Maerkisch-Oderland^{ref1, ref2}.
• Bavaria^{ref1, ref2, ref3} (71 wild birds; 18 counties affected^ref) : 8 birds (5 laboratory-confirmed). On Feb 28 a mute swan (Cygnus olor) found dead on Feb 20 in the town of Schwabstadl in the district Landsberg am Lech, and a wild mallard duck (Anas platyrhynchos) found dead on Feb 20 in the town of Sachsenkam in the district Bad Tolz Wolfratshausen tested positive for H₅N₁. The protection zones around the upper Bavarian Landsberg discovery point also reach into the Schwabian district of Augsburg-Land. There are 20 poultry farms in the restricted area around the district of Landberg am Lech, the largest with 150 chickens; the remaining have between 10-30 birds. In the restricted area of the district of Bad Tolz-Wolfratshausen, there are 5 small poultry farms, and in the observation area, there are 46 small poultry farms^ref. On 8 Mar 2006 a common buzzard (Buteo buteo) found dead on Feb 28 in Wasserburg on Lake Constance (district Lindau) and a mute swan found dead on Mar 2 in the town of Landsberg am Lech tested positive for H₅N₁^ref. So far in 2006, 6843  wild birds have been handed over to the Bavarian Agency for Health and Food Safety; 6084 of them have already by 28 Apr 2006 been tested for influenza A, and the 90 samples that were influenza A positive have been sent to the Friedrich Loffler Institute (FLI) for further^ref

No. / Municipality / Administrative or City District / Regional District / Species / Date H₅N₁ confirmed :
• Harburg / Danube-Ries / Bavaria / Swan / 2 May 2006
• Denklingen / Landsberg on the Lech / Bavaria / Merganser / 28 Apr 2006
• Parkstetten / Straubing (town) / Bavaria / Mute Swan / 28 Apr 2006
• Kirchroth-Nierachdorf / Straubing (town) / Bavaria / Mute Swan / 26 Apr 2006
• Kirchroth-Muenster / Town of Straubing / Bavaria / Mute Swan / 26 Apr 2006
• 71/ Parkstetten/ Straubing-Bogen / Lower Bavaria / Swan / 28 Apr 2006
• 70/ Epfach / Landsberg on the Lech / Upper Bavaria / Merganser / 28 Apr 2006
• 69/ Steinach / Straubing-Bogen / Lower Bavaria / Swan / 27 Apr 2006
• 68/ Kirchroth / Straubing-Bogen / Lower Bavaria / Swan / 27 Apr 2006
• 67/ Olching / Fuerstenfeldbruck / Upper Bavaria/ Duck / 24 Apr 2006
• 66/ Olching / Fuerstenfeldbruck / Upper Bavaria/ Duck / 24 Apr 2006
• 65/ Lindau / Town of Lindau / Schwabia / Crested Grebe / 24 Apr 2006
• 64/ Stephansposching / Deggendorf / Lower Bavaria / Swan / 24 Apr 2006
• 63 / Burghausen / Altoetting / Upper Bavaria / Gadwell Duck / 20 Apr 2006
• 62 / Oeberau / Town of Straubing / Lower Bavaria / Falcon /20 Apr 2006
• 61 / Oberottmarshausen / Augsburg / Schwabia / Owl / 13 Apr 2006
• 60 / Strasslach-Dingharting / Munich / Upper Bavaria / Owl / 13 Apr 2006
• 59 / Schwenningen / Dillingen on the Danube / Schwabia / Mute Swan / 13 Apr 2006
• 58 / Schwenningen / Dillingen on the Danube / Schwabia / Mute Swan /13 Apr 2006
• 57 / Lauingen / Dillingen on the Danube / Schwabia / Merganser / 12 Apr 2006
• 56 / Lindau / Lindau / Schwabia / Duck / 12 Apr 2006
• 55 / Gunzenhausen / Weissenburg-Gunzenhausen / Middle Franconia / Swan / 7 Apr 2006
• 54 / Elchingen / New Ulm / Schwabia / Tufted Duck / 6 Apr 2006
• 53 / Elchingen / New Ulm / Schwabia / Tufted Duck / 6 Apr 2006
• 52 / Lindau on Lake Constance / Lindau / Schwabia / Duck / 6 Apr 2006
• 51 / Gstadt / Rosenheim / Upper Bavaria / Duck / 6 Apr 2006
• 50 / Passau /City of Passau / Lower Bavaria / Duck / 6 Apr 2006
• 49 / Munningen /Danube-Ries / Schwabia / Swan / 6 Apr 2006
• 48 / Gunzenhausen / Weiþenburg-Gunzenhausen / Middle Franconia /  Swan / 6 Apr 2006
• 47 / Elchingen / New Ulm / Schwabia / Mallard Duck / 3 Apr 2006
• 46 / Krun / Garmisch-Partenkirchen /  Upper Bavaria / Merganser / 3 Apr 2006
• 45 / Kelheim / Town of Kelheim / Lower Bavaria / Tufted Duck / 3 Apr 2006
• 44 / Ornbau / Ansbach / Middle Franconia / Swan / 3 Apr 2006
• 43 / Ornbau / Ansbach / Middle Franconia / Swan / 3 Apr 2006
• 42 / Merkendorf / Ansbach / Middle Franconia / Swan / 3 Apr 2006
• 41 / Dachsbach / Neustadt on the Aisch / Middle Franconia / Swan / 3 Apr 2006
• 40 / Gutenstetten Neustadt on the Aisch / Middle Franconia / Swan / 31 Mar 2006
• 39 / Merkendorf / Ansbach / Middle Franconia / Swan / 31 Mar 2006
• 38 / Straubing / Town of Straubing / Lower Bavaria / Swan / 30 Mar 2006
• 37 / Straubing / Town of Straubing / Lower Bavaria / Swan / 27 Mar 2006
• 36 / Oberau (Town of Straubing) / Town of Staubing / Lower Bavaria / Buzzard / 27 Mar 2006
• 35 / Sterpersdorf (Town of Hochstadt on the Aisch) / Erlangen-Hochstadt / Middle Franconia / Swan / 24 Mar 2006
• 34 / Merkendorf / Ansbach / Middle Franconia / Swan / 24 Mar 2006
• 33 / Nurnberg-Grosreuth / City of Nurnberg / Middle Franconia / Falcon / 24 Mar 2006
• 32 / Teublitz / Schwandorf / Upper Palatinate / Buzzard / 24 Mar 2006
• 31 / Sterpersdorf / Erlangen-Hochstadt / Middle Franconia / Mute Swan / 24 Mar 2006
In addition to avians, 277 carnivores (martens, foxes, cats) have been sent to the LGL; 269 have been tested for influenza A virus. One influenza A positive sample has been forwarded to the FLI, where it was found H₅N₁ negative^{ref1, ref2, ref3,ref4}. Though the incidence (or, rather, detection rate) of H₅N₁ infection in wild birds in Bavaria continues to maintain a constant pace (3-5 cases per week), the spectrum of the affected/detected birds seems to shift from aquatic birds to raptors. Explanatory attempts from ornithologists will be welcomed.
• Berlin authorities said on Fri Mar 24, 2006, they had detected the lethal strain of H₅N₁ bird flu in a dead wild buzzard, the first case of the virus in the German capital. The bird was found in the Marzahn-Hellersdorf district on the eastern edge of the city^ref
• Lower Saxony : at a poultry farm in the village of village Raum Mutzschen^ref/Wermsdorf^{ref1, ref2, ref3}, district Muldentalkreis about 20 km southeast of Wurzen (east of Leipzig), with > 8,000 turkeys (as in the first commercial outbreak in France), 5,000 geese and 2,000 chickens, birds started dying on Sun 2 Apr (susceptible 14,300, 801 cases, 800 deaths, 13,500 destroyed) : tests on 20 turkeys showed the presence of the H₅ virus : H₅N₁ was confirmed on Apr 5^{ref1, ref2, ref3}. The protection zone covers Wermsdorf, Stadt Mutzschen, while municipalities in the districts of Muldentalkreis, Kreis Torgau-Oschatz and Kreis Dubeln fall within the surveillance zone or the wider risk area^ref : some 14,000 more fowl will be slaughtered^ref.
• Free State of Saxony : the 1st suspected case involved a tufted duck (Aythya fuligula) from the administrative district of Bautzen^{ref1, ref2}. A sample was sent on 25 Apr 2006 and tested positive for H₅N₁ on 26 Apr. A 3 km radius restricted area (21 day transport ban for poultry, birds and their products) has been established around the discovery point in area about the Bautzen dam (located north of the city of Bautzen, a part of the municipalities of Radibor, Grossdubrau and Malschwitz); a 10 km radius observation area (30 day transport ban for poultry and

birds) has been declared around the discovery site. In both restricted areas, dog leashing is prescribed, and cats are required to stay indoors^ref.
• Brandenburg state : Maerkisch-Oderland district : Letschin municipality : a white stork on 26 Apr 2006 and another on 3 May 2006
Health officials urged cat owners to keep pets indoors and dogs on leashes in reported bird flu areas in the 5 states.
• Denmark^ref : 13 birds. on Feb 15 9 dead swans have been found on Falter Island and Bornholm island. Falter Island is just 30 miles from the German island of Ruegen, where bird flu-infected swans were found^ref. Both islands are in the Baltic sea^ref. Other birds were found dead on Lolland and Sealand islands. On Mar 15, 2006, 35 birds on the Baltic islands of Bornholm & Mon^ref, north of Germany, were found infected^ref. On Tue 14 Mar 2006, an H₅ avian influenza virus was detected in respiratory tissues from a dead buzzard (Buteo buteo) found in Svinoe Strand, south of Copenhagen, in the southern part of the island of Zealand (Sjaelland)^{ref1, ref2}. The identification of A/Buzzard/Denmark/6370/06 (H₅N₁) by the Danish Institute for Food and Veterinary Research in 11 of the 14 H₅-positive tested wild birds was reported by Denmark to the OIE in follow-up report No. 1, sent on 24 Mar 2006^ref : it was confirmed by VLA on 29 Mar 2006 as the same strain of the virus that has previously been found in Germany and Poland^ref. Sequencing of the cleavage site of the HA gene revealed that the virus is highly pathogenic for fowl. On Wed 15 Mar 2006, a virus isolate was obtained from SPF [specific pathogen free] chicken embryos. The entire viral genome has been sequenced now in a collaborative work between the Danish Institute for Food and Veterinary Research (DFVF) and Statens Seruminstitut (SSI). The sequence has been made accessible at the home page of the Danish Influenza Research Network, formed by DFVF and SSI. Preliminary analysis of the sequences indicates that the HA gene has high homology with A/Cygnus olor/Astrakhan/Ast05-2-4/2005 (H₅N₁) and the NA gene with A/Cygnus olor/Astrakhan/Ast05-2-7/2005 (H₅N₁). There are no neuraminidase substitutions in the NA gene. Russia's authorities reported the mortality of 558 swans (out of a population estimated to be 15 000) in the hunting refuge "Astradelta", in the Volga delta area, Astrakhan, in November 2005. The data, presented in a table, were included in Russia's official follow-up report No. 5 to the OIE for 2005^ref. Phylogenetic trees constructed from fragments of the HA gene (nucleotides 801-1113) and NA gene (nucleotides 605-937) showed that Russian isolates of the year 2005 exhibited greatest sequence similarity with the A/Qinghai/05 H₅N₁ group of isolates. The HA gene homology was shown, among others, in the isolate A/swan/Astrakhan/04/05. Further analysis of the genome will be performed. This is the 1st time highly pathogenic avian influenza has been detected in Denmark. The virus isolate was submitted to the EU reference laboratory in the UK on Thu 16 Mar 2006 for confirmation^ref. The Danish Veterinary and Food Administration is implementing measures in accordance with Commission Decision 2006/115/EC including establishing protection and surveillance zones on both locations^ref.  In Denmark, 225 wild birds were analyzed in the period 15 Feb 2006 to 15 Mar 2006 with negative test results. However, following the detection of the 1st positive bird, on 14 Mar 2006, 26 additional H₅-positive wild birds have been confirmed between 15 Mar 2006 and 31 Mar 2006^ref.
• outbreak in Praesto, Storstroem: a tufted duck (Aythya fuligula); 55 07'18; 12 02'55' Lat. Long
• outbreaks in the marine of the town of Aeroskobing^ref, on the small island of Aeroe in the south of the country^ref., Funen: 11 tufted ducks (Aythya fuligula); 54 53'37; 10 24'41' Lat. Long, on 20 Mar : H₅, N typing pending^ref
• outbreak in Frederikssund, North Eastern Zealand: a whooper swan (Cygnus cygnus). 55 50'42; 12 02'35' Lat. Long, on 20 Mar : H₅, N typing pending^ref
• outbreak in Bornholm: a mute swan (Cygnus olor) near Vang
• outbreak in Fredriksborg: a rough-legged buzzard (Buteo lagopus) near Skibby
• outbreaks in Funen: 6 tufted ducks (Aythya fuligula) in Aeroskobing, a peregrine falcon (Falco peregrinus) on the island Drejo, a greyleg goose (Anser anser) near Svendborg, 2 mute swans (Cygnus olor), a tufted duck (Aythya fuligula) and a common buzzard (Buteo buteo) near Fåborg
• outbreaks in Southern Jutland: a common buzzard (Buteo buteo) near Sønderborg, a tufted duck (Aythya fuligula) on Kegnæs : on 30 Mar 2006 HPAI H₅^ref
• outbreaks in Storstroem: a tufted duck (Aythya fuligula) in Guldborgsund, a common buzzard (Buteo buteo) near Nysted, a tufted duck (Aythya fuligula) near Stubbekøbing, a tufted duck (Aythya fuligula) near Bandholm
• outbreak in Western Zealand: a tufted duck (Aythya fuligula) near Skælskør, on 31 Mar 2006 and in a mute swan (Cygnus olor) found dead near Vang on the island Bornholm
• Denmark reported on 7 Apr 2006 the confirmation of 3 additional cases in wild birds: 2 common buzzards (Buteo buteo) and one whooper swan (Cygnus cygnus), in 3 separate locations^ref.
• outbreaks in Fredriksborg a common buzzard (Buteo buteo) in Hornbaek (56°04'12" N by 12°24'51" E) and a mute swan (Cygnus olor) in Skibby (55°44'13" N by 11°59'32" E)
• outbreak in Funen Ullerslev (55°22'32" N by 10°38'26" E) : a common buzzard (Buteo buteo)
• outbreaks in Storstroem: 2 whooper swans (Cygnus cygnus) in Nysted (54°40'02" N by 11°44'32" E) and Nysted 54°40'02" N by 11°44'32" E)^ref
• on 2 May 2006, the Danish Veterinary and Food Research Institute detected high pathogenic avian influenza (H₅) in a great crested grebe (Podiceps cristatus), which was found in the town Grasten in South Jutland County on 28 Apr 2006.
716 dead wild birds were tested for the presence of avian influenza at the Danish Veterinary and Food Research Institute during the 1st 3 months of 2006. Since 14 Mar 2006, when the first H₅N₁-positive case was detected in Denmark, a total of 43 positive cases have been confirmed, most of them (26) in Funen county (in Danish, Fyns Amt). They included the following species^ref :
• tufted ducks (Aythya fuligula): 26
• common buzzard (Buteo buteo): 6
• mute swans (Cygnus olor) : 4
• whooper swan (Cygnus cygnus): 3
• peregrine falcon (Falco peregrinus) 1
• greylag goose (Anser anser): 1
• rough-legged buzzard (Buteo lagopus): 1
• great crested grebe (Podiceps cristatus): 1
The infected birds in Funen were :
• 16 tufted ducks (Aythya fuligula)
• 2 mute swans (Cygnus olor)
• 2 common buzzards (Buteo buteo)
• 1 peregrine falcon (Falco peregrinus)
• 1 greylag goose (Anser anser)
Their respective dates of laboratory confirmations were the following:
• 14/03/2006 1 common buzzard (Buteo buteo)
• 17/03/2006 9 tufted ducks (Aythya fuligula)
• 19/03/2006 6 tufted ducks (Aythya fuligula)
• 21/03/2006 1 whooper swan (Cygnus cygnus)
• 22/03/2006 1 tufted duck (Aythya fuligula)
• 22/03/2006 2 tufted ducks (Aythya fuligula)
• 24/03/2006 1 peregrine falcon (Falco peregrinus)
• 25/03/2006 1 greylag goose (Anser anser)
• 25/03/2006 1 tufted duck (Aythya fuligula)
• 27/03/2006 2 mute swans (Cygnus olor) 1 tufted duck (Aythya fuligula)
• 27/03/2006 1 common buzzard (Buteo buteo)
• 27/03/2006 1 tufted duck (Aythya fuligula)
• 27/03/2006 1 rough-legged buzzard (Buteo lagopus)
• 29/03/2006 1 common buzzard (Buteo buteo)
• 30/03/2006 1 tufted duck (Aythya fuligula)
• 31/03/2006 1 mute swan (Cygnus olor)
• 31/03/2006 1 tufted duck (Aythya fuligula)
• 01/04/2006 1 tufted duck (Aythya fuligula)
• 01/04/2006 1 common buzzard (Buteo buteo)
• 06/04/2006  1 whooper swan (Cygnus cygnus)
• 07/04/2006  1 common buzzard (Buteo buteo)
• 07/04/2006 1 common buzzard (Buteo buteo)
• 10/04/2006 1 swan (Cygnus spp.)
• 10/04/2006 1 swan (Cygnus spp.)
On Sat Apr 15, 2006, a 25-year-old man who had contact with bird excrement for his job tested positive for bird flu and was transferred from the hospital in Nykoebing on the island of Falster to the Royal Hospital in Copenhagen^ref, but the result of an examination by specialists showed that he was not infected^ref. Denmark produces about 136 million chickens annually, or about 3 billion Danish crown's worth, with about 66% going to export. H₅ virus was found in a petting farm in Hundslev^ref, on Fyn island in the centre of the country (first case in domestic birds in Denmark)^{ref1, ref2}. An outbreak of H₅N₁ was reported at Kerteminde^ref in Funen county on 18 May 2006 : the animals affected are backyard poultry (47 cases and 102 susceptible). 51 chickens, 41 ducks, 5 geese, 3 guinea fowls and 2 peacocks became infected -- 47 of the birds died and the remaining 55 animals were slaughtered and a quarantine zone set up^ref.
The identification and management of H₅N₁ avian influenza in Denmark in 2006 has been facilitated by close collaboration between the animal and human health authorities and institutions, at national and local level. Public expressions of concern have been well-informed and calm, and media reporting has been responsible. Avian influenza A/H₅N₁ is currently not a very contagious virus for humans, but there is a small and real risk of infection for people who have close contact with sick birds. Even in an industrialised country with a well-informed population, delays in case ascertainment affect the management of an outbreak. At present, it is impossible to know whether avian influenza H₅N₁ has become endemic in Danish wild birds, or, if it has not, whether it is likely to be reintroduced later. It is therefore important to maintain timely surveillance, preparedness and communication lines between the relevant stakeholders.
Wild birds : the first detection of highly pathogenic avian influenza A H₅N₁ in Denmark was on 14 Mar 2006 in a common buzzard (Buteo buteo) found on Svino near the town of Naestved in the southern part of Sjaelland. Subsequently highly pathogenic avian influenza A H₅N₁ was found in 43 wild birds through passive surveillance in various locations in Denmark, mainly areas bordering the Baltic Sea along the Eastern migratory flyways. Avian influenza has also been detected in a pooled sample of herring gull (Larus argentatus) faeces. Among the various types of bird tested, the rates of positive findings have been highest in waterfowl, particularly swans and ducks. The most recent positive findings in wild birds were made on 2 May
2006. More detailed information is available in Danish and English from the Danish Veterinary and Food Administration^ref.
Backyard poultry holding : an outbreak of highly pathogenic avian influenza A H₅N₁ in a poultry flock was confirmed on 18 May 2006. It occurred in a backyard holding in Funen county, in an area where avian influenza A H₅N₁ had previously been detected in wild birds. The flock consisted of 102 birds (51 chickens, 41 ducks, 5 geese, 3 guinea fowls, and 2 peacocks) of which 47 died between 3 and 12 May 2006. The birds were kept in 4 different sections located on different parts of the farm, and the sick birds all belonged to the same section which held about 50 birds. The birds in the affected section were all free-ranging and thus exposed to wild birds. When the owner became aware of the outbreak, he implemented biosecurity measures. Changes of clothing and footwear seemed to be sufficient to prevent the spread of the disease to the other sections. All the birds from the 3 non-affected sections were culled, but were tested H₅N₁-negative. The 2 people living on the farm both had close contact with the birds. They culled sick birds on their own initiative without using any personal protective devices such as masks or gloves. They reported that they got bird blood on their bare hands during this process. In addition, there had been visitors at the farm on more than one occasion, including a person who came on 8 May, and 3 visitors who purchased eggs for home cooking use on 10 May. There was a considerable delay between the onset of the outbreak on 3 May 2006 and the notification to the district veterinary officer on the evening of 17 May 2006. By 18 May, a total of 6 people had been directly exposed to sick poultry since 3 May. These included the 2 people living on the farm, one of the 3 visitors who came to purchase eggs on 10 May, and a veterinarian and 2 cullers (personal protective devices were used by the veterinarian and the cullers). Following guidance from the WHO and the European Centre for Disease Prevention and Control, these 6 persons were all recommended to take oseltamivir for post-exposure prophylaxis (which they duly accepted), and were asked to report any illness with fever to the local public health authority^{ref1, ref2}. The owners were also instructed to keep out of the areas where the birds had been until these areas had been cleaned and disinfected by a contracted cleaning company. No one developed signs or symptoms compatible with human infection with avian influenza virus.A family of 5 had received a delivery of fresh table eggs from the farm on 16 May, and ate these eggs fried (that is, with runny, partially cooked yolks) the following day. As a precautionary measure, these individuals were recommended oseltamivir prophylaxis on 20 May. One of the family members developed a sore throat on 18 May, but the family doctor, in consultation with specialists in infectious disease, did not judge the signs to be compatible with avian influenza in humans and it was decided that testing was not justified. No other symptoms have been reported from this family. The visitor who came on 8 May has since been well, with no symptoms of influenza-like illness, and was not prescribed antiviral drugs, since more than 10 days had already passed since exposure. 2 of the 3 visitors who came on 10 May stayed at the farmhouse and were not directly exposed to the birds, and were consequently not offered antiviral drugs. Another delivery of fresh table eggs was made from the farm to a household on 15 May; and although it is theoretically possible that these individuals may have been exposed to avian influenza virus, they were not offered antiviral drugs because they reported that they did not cook, eat or otherwise handle the eggs but kept them in their packaging in the refrigerator.
Game bird holding : on 2 Jun 2006, low pathogenic avian influenza H₅N₂ was detected in a game bird holding, also in Funen county. There were no reported clinical signs of disease among the animals. Mallard (Anas platyrhynchos) ducklings from the holding were tested as part of the Danish surveillance programme for avian influenza in poultry. At the initial testing, the virus was found to be A/H₅, but the neuraminidase type was unknown. Although a highly pathogenic avian influenza (such as A H₅N₁) was considered to be unlikely, given the absence of bird deaths, it was considered reasonable to offer the owners and the personnel working at the holding antiviral drugs for post exposure prophylaxis. Nearly 90 people had recently purchased live ducklings from the holding and 50 people had been involved in the culling of the 19 500 birds, and all were eligible for post exposure prophylaxis. However, before prophylaxis could be offered to the duckling purchasers and cullers, it became clear that the viral strain was a low pathogenic H₅ type that had not been described as a cause of illness in humans. Therefore, the prophylaxis was not distributed to this group, and treatment of the owners and the personnel working at the holding who had already started a course of prophylaxis was discontinued^ref.
• The Netherlands, where land is scarce and canals, rivers and ditches are abundant, is home to 16 million people and 90 million poultry. It  is Europe's 2nd biggest poultry producer, after France and one of the world's top poultry exporters (1.6 billion euros a year). The Netherlands' main poultry markets are Germany, Britain, Belgium, France, Ukraine, Japan, Poland and Russia. On Jan 12, 2006 the farm ministry said it was not necessary for now to reintroduce a ban on keeping poultry indoors to prevent them from catching bird flu from migrating birds. It lifted the ban on 1 Jan 2006 as the peak period for birds migration was over. On Fri, 17 Feb 2006 Dutch vets found no bird flu in 2 dead swans found in 2 different towns in central Netherlands^ref. The Dutch plan approved by EU on Feb 22 entails vaccinating hobby poultry and free-range laying hens throughout the whole country with an inactivated H₅N₂ (DIVA) vaccine. The vaccination will be provided on a voluntary basis, as an alternative to the requirement that these birds be kept indoors^ref. In the Netherlands, vaccination has been approved for hobby birds (poultry kept by households for strictly personal use), as well as free-range laying hens throughout the whole country as an alternative to bringing birds indoors. Biosecurity measures are mandatory whether the owners have vaccinated poultry or not. Vaccinated hobby poultry will only be allowed to be moved to another vaccinated holding, and only with permission from authorities. Meat and meat products from hobby poultry are not permitted to be commercially traded anyway, so no extra regulations are required. For vaccinated free-range commercial poultry, there will be strict limits on movements within the Netherlands, and a ban on movement to any other countries. The Dutch plan contains mandatory surveillance and control measures for vaccinated commercial poultry. Full bio-security measures will be required. Eggs, meat and meat products from vaccinated Dutch flocks will be permitted to be traded within the EU, provided the farms and packagers have fully complied with the strict regulations in place^ref. Dutch authorities launched a postponed voluntary vaccination campaign against bird flu from Thu 16 Mar 2006 until 30 Jun 2006 for birds older than 7 months. The European Union approved the Dutch vaccination plan on 22 Feb 2006. The Ministry of Agriculture, Nature and Food Quality has drawn up a plan for the vaccination and ensured that vaccine is approved and available: 4 million doses of Gallimune Flu H₅N₉ from supplier Merial. The European Commission places several conditions on vaccination. No vaccinated poultry may be taken across the border and must be slaughtered in the Netherlands. Meat from vaccinated birds may be exported^{ref1, ref2, ref3}
• 1. Protection vaccine : The vaccine will protect the birds for a maximum period of 12 months. Vaccinated birds are less susceptible to infection. In most cases, they will not catch the disease themselves. Infected vaccinated birds excrete far less of the virus, which substantially reduces the risk of other animals getting infected. Not enough is known about the effect of vaccination in animals other than chickens, ducks, geese and turkeys.
• 2. Vaccination is voluntary : Keepers of hobby poultry and free-range chickens can decide for themselves whether to vaccinate their flocks or keep them under cover. Two or 3 weeks after the 2nd vaccination (this depends on vaccine specifications), vaccinated birds are allowed outside again. In the event of an outbreak, culling may include vaccinated flocks. This will depend on the scale of the outbreak. Culling will only be carried out if this is absolutely necessary from a veterinary point of view.
• 3. Veterinarian : Keepers of hobby poultry and free-range chickens who want to have their birds vaccinated should ring their veterinarian. The veterinarian vaccinates on site. Hobby poultry keepers may only vaccinate chickens, turkeys, ducks and geese. All hobby birds to be vaccinated are fitted with a leg ring bearing the text "Vaccinatie AI 2006 NL". Commercial poultry farmers may only have their free-range laying hens vaccinated. Vaccination requires 3 visits. The 1st time the veterinarian comes around for vaccination, identification and registration of the birds. The 2nd visit is for the 2nd vaccination. During the 3rd visit, the veterinarian will take blood samples. The costs for the keeper depend on the size of the flock and the veterinarian's fees, but will come down to an average 100 to 200 euros [USD 123.41 to 246.82] per keeper. Each vaccinated bird will be identified and registered.
• 4. Ex