12/31 H5N1 | Pan Africa Faces Onslaught / US Tightens Borders

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<B><font size=+1 color=red><center>[Bird Flu] Mystery surrounds 7th human infection</font>

Latest Updated by 2005-12-31 10:00:21
<A href="http://www.newsgd.com/news/China1/200512310012.htm">www.newsgd.com</a></center>
China reported its seventh human infection of H5N1 bird flu on Thursday (Dec 30), but questions remain over where the virus actually came from.

The victim, surnamed Zhou, from Meilie District of Sanming City in East China's Fujian Province, had never been into contact with infected birds or poultry before.</b>

All 66,172 poultry raised within 3 kilometres of Zhou's home had been immunized by December 5.

No bird flu outbreak had happened previously in the district, and no abnormal poultry deaths had been found since this autumn, local officials said.

Investigators tested and culled 230 poultry in the nearby area as soon as the case was reported, but no virus was found.

The infection source is still being investigated, the Ministry of Health said.

"Zhou is unlikely to have been infected from poultry," said Xu Longshan, honorary director of Fujian Provincial Disease Prevention and Control Centre.

Zhou, a 41-year-old female worker, died on December 21.

After undergoing a thymus tumour excision operation in mid-October, Zhou became weak and caught fever on December 6. She was treated in a local hospital two days later, with symptoms of continuous fever and pneumonia.

Tests on December 23 by the Chinese Centre for Disease Prevention and Control were positive for H5N1 virus.

The case was not reported until December 29 because experts could not explain how she caught the virus, an official of the Ministry of Health, who refused to be identified, told China Daily.

Those who had had close contact with the woman were tested, and they are all healthy.

Zhou's relatives said that she didn't like to eat chicken and duck, and she did not have close contact with or eat ill birds. Also, no outside visitors or patients came to the family around the time of possible infection.

She lived in an urban area with good sanitation conditions. The previous six cases were mostly reported in rural areas, where the victims had close contact with infected poultry.

The WHO office in Beijing has been informed about the case, but it is also quite confused about the infection channel, Roy Wadia, spokesman of the office, said.

In many of the other human cases on the Chinese mainland this year, it was only after a probe began that authorities realized there had been bird flu outbreaks in the area, Wadia noted.

This points to the challenges of the animal surveillance process.

"Chinese officials have acknowledged this and other challenges, and there is a commitment to improving the situation but change won't occur overnight," Wadia said.

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<B><font size=+1 color=brown><center>Another man dies of suspected bird flu in Indonesia </font>

Web posted at: 12/31/2005 3:7:52
Source ::: AFP
<A href="http://www.thepeninsulaqatar.com/Display_news.asp?section=World_News&subsection=Rest+of+the+World&month=December2005&file=World_News200512313752.xml">The Peninsula Online</a></center>
JAKARTA: Indonesia's bird flu death toll may have risen to 12 with the death of a 48-year-old man in Central Java who was strongly suspected of being infected with the virus, a health official said yesterday. </b>

The man was admitted to the Tidar state hospital in Central Java's Magelang suffering high fever and respiratory problems, said Nurul Safariah, the city's chief health administrator. She said the man died after 10 hours of treatment.

"We have sent his blood samples to be tested by the national bird flu monitoring center in Jakarta, which will further send the samples to the (World Health Organisation-affiliated) lab in Hong Kong," Safariah said.

She added that blood samples had been taken from the victim's relatives and neighbours for further testing.

Health authorities here test suspected cases locally before sending positive results to facilities overseen by the WHO abroad for verification.

Scientists warn that continued contact between infected birds and humans may eventually result in the virus mutating into a form that could be easily passed on by humans, sparking a pandemic with a potential toll of millions.

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<B><font size=+1 color=green><center>H5N1 Human Transmission in Fujian Province?</font>

<A href="http://www.recombinomics.com/News/12300501/H5N1_Fujian_Human.html">Recombinomics Commentary</a>
December 30, 2005</center>
On 13 December, initial laboratory tests on samples from the patient tested negative for H5N1. But further tests on 23 December – including PCR tests carried out at the Chinese Center for Disease Control in Beijing – showed positive results. The virus was also isolated from the patient.</b>

Agricultural authorities so far have not been able to confirm the presence of the H5 virus subtype in poultry in the vicinity of the patient’s residence or place of work. Investigators have not been able to confirm any direct contact between the patient and poultry prior to the onset of illness.

This is China’s seventh laboratory-confirmed human case. Of these cases, three have been fatal (including this latest case). To date, China has reported human cases in six provinces and regions: Hunan, Anhui, Guangxi, Liaoning, Jiangxi and Fujian.

The above comments from the latest WHO report on H5N1 rause more concerns about human to human transmission. More information about the isolated virus would be useful. Currently, only one isolate from Fujian Province from 2005 is available at GenBank, but the sequence suggests closely related H5N1 isolates are present throughout eastern China, raising concerns over human transmission via various H5N1 strains.

China’s first reported human H5N1 infection was only a few months ago and already cases have been confirmed in six eastern provinces. Tracing polymorphisms of the 2005 isolate (A/Duck/Fujian/1734/05(H5N1) indicates that it shares some polymorphisms with the H5N1 isolates from Hong Kong in 1997 as well as the Hong Kong isolates from the family that visited Fujian Province in 2003. In addition several polymorphisms found in the 2004 and 2005 isolates in southeast Asia are also present in the 2005 Fujian isolate.

The HA cleavage site, RERRRKR, matches a 2003 isolate from a duck (A/duck/China/E319-2/03(H5N1)) that was being smuggled from Fujian Province to Taiwan. The same cleavage site is also found in more recent isolates from Guangdong and Hunan Province.

Other polymorphisms are found in isolates from Hubei as well as tree sparrows in Henan and isolates from Indonesia. The various combinations of polymorphisms suggest these isolates are related but distinct, significantly increasing the number of H5N1 strains that can infect humans.

Publication of the sequences of the H5N1 isolates from humans and poultry would aid in efforts to determine how rapidly H5N1 is evolving toward more efficient human to human transmission.

The failure to identify a poultry source for the most recent case is cause for increased concern.

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<B><font size=+1 color=blue><center>H5N1 avian flu viruses: What's in a name?</font>

Robert Roos and Amy L. Becker Staff Writers
<A href="http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/dec3005halvorson.html">CIDRAP</a></center>
Dec 30, 2005 (CIDRAP News) – Last month, officials in Italy and Canada aroused concern by announcing they had found an H5N1 influenza virus in wild birds. Neither country had previously been troubled by any reports of the virulent H5N1 virus that has been plaguing poultry and occasionally sickening and killing humans in Asia. </b>

But in both cases, health officials said the virus was not dangerous and was unrelated to the H5N1 virus in Asia.

This suggested an obvious question: If a virus has the same name as the one in Asia, why isn't it just as dangerous?

The answer has to do with the rather outdated conventions for naming influenza viruses, according to David Halvorson, a veterinary pathologist and avian influenza expert at the University of Minnesota in St. Paul.

The "H" and "N" in the name of a flu virus stand for hemagglutinin and neuraminidase, two proteins on the surface of the virus that allow it to enter and exit host cells. Sixteen different hemagglutinins and nine different neuraminidases have been identified to date.

Hemagglutinin and neuraminidase were the first aspects of the flu virus to be identified, so the nomenclature was built around the two genes that code for them, Halvorson explained to CIDRAP News. The types are numbered according to when they were discovered; H1 was identified first.

However, a flu virus also has six other genes and corresponding proteins. Thus a name like "H5N1" is a very incomplete description of the virus.

"The H5N1 only describes two of the eight genes, so there are six other genes," Halvorson said. It's possible to have an H5N1 strain with six other genes from an avian flu virus, or an H5N1 with six other genes from a human-adapted or pig-adapted flu virus. "That's how far apart they can be."

For example, the other six genes in a given H5N1 virus could be identical to the other six genes in an H6N2 virus, he said.

In an analogy Halvorson uses with his students, he said that assuming that all H5N1 viruses are identical would be like assuming that all men wearing navy blazers and gray pants are the same in other ways.

"You can have the mafia wearing that outfit or you can have a college professor wearing that outfit—or a used car salesman," he said.

"We're stuck with something we have difficulty explaining because we don't really have good nomenclature," Halvorson summed up.

Mild viruses can turn nasty
Avian flu viruses of the H5 and H7 types can be either relatively harmless or highly lethal to poultry—low-pathogenic or highly pathogenic. (The conventional abbreviations are LPAI and HPAI, for low-pathogenic and highly pathogenic avian influenza.) In fact, all known HPAI strains are either H5 or H7 subtypes.

HPAI strains typically are detected as a result of poultry deaths, Halvorson said. The designation of high pathogenicity generally is based on what happens to healthy chickens when they're exposed to the virus. If the virus kills at least 6 out of 8 chickens in a challenge trial, it is deemed highly pathogenic.

Unfortunately, a low-pathogenic strain won't necessarily stay that way. It can evolve unpredictably into a highly pathogenic strain—a change that may take weeks, months, or even years.

What differentiates LP from HP strains at the molecular level, Halvorson explained, is the nature of the hemagglutinin cleavage site, where the hemagglutinin is split by an enzyme or some other factor, enabling the virus to enter a host cell.

In most human and poultry flu cases, the virus is cleaved by protease, an enzyme found in the respiratory tract, Halvorson said. But an HPAI virus doesn't need that protease assistance to split; "It gets cleaved almost by itself." Consequently such viruses can spread in many tissues, not just the respiratory tract.

Scientists now can identify HPAI viruses not only by how they affect chickens, but also by examining the amino acid sequences at the hemagglutinin cleavage site, according to Halvorson. (Most of the time, however, HPAI viruses are detected by their effects on poultry.)

Generally, HPAI viruses are defined by having four basic (as opposed to acidic) amino acids at the cleavage site, he said. However, in the last few years there were two cases in which an HPAI virus emerged without those four basic amino acids. Those viruses had an insert from another gene at the cleavage site that allowed it to split more easily. The outbreaks involved H7 strains in Chile in 2002 and in British Columbia in 2004.

Viral instability tough on poultry industry
Those outbreaks illustrated once again the highly unstable nature of flu viruses. Mutations occur constantly as the virus tries "to find the best fit for the species" it depends on, Halvorson said.

Flu viruses, including H5 and H7 varieties, circulate all the time in wild waterfowl, usually without making them sick. "Occasionally there's going to be spillover into poultry someplace. Even though it may be low-path, it's cause for concern," he explained.

The US poultry industry is "99.99% free of influenza," but every year flu turns up in one or more flocks in one or several states, he added.

When the strain is a low-pathogenic H5 or H7, there's no way to predict if, or how soon, it might evolve into a highly pathogenic form. In the outbreaks in Chile and British Columbia, the transition took just a few weeks. But in Pennsylvania in 1983, it took 6 months. And a low-pathogenic H7N2 virus has persisted in live-bird markets in New York since 1994 without changing into the lethal form.

The World Organization for Animal Health (OIE) recently recommended that all low-pathogenic H5 and H7 avian flu outbreaks be reported to veterinary authorities, given the risk that they can turn virulent, Halvorson said. This has increased the level of awareness and concern about the viruses.

"So states like Minnesota, which never destroyed any poultry before, if we were to get an H5 or an H7 [that's low-pathogenic], we'd be under tremendous pressure to destroy the flock," he noted.

The heightened concern has economic consequences. Halvorson said there's no legal basis for banning poultry imports from an area where LPAI has been found, yet the US Department of Agriculture promptly (though temporarily) banned poultry from British Columbia recently when an LPAI strain turned up there.

H5N1 may lead to use of risky vaccines
As the virulent H5N1 virus continues to evolve and kill poultry in Eurasia, Halvorson predicted, scientists may turn toward a hitherto unthinkable option: a live influenza vaccine for poultry. Such vaccines use a live but weakened form of flu virus.

Such vaccines have long been considered too risky in poultry. "Because these viruses are so unstable, the concern was that they could recombine with some other virus that's there and make something worse," he said.

But with the H5N1 virus now present in 15 or more countries and endemic in several of them, using a live vaccine may be worth the risk, he said. "People are now saying we've got to attack this with everything at our disposal, and that'll have to include a live vaccine. The door is open now for a live H5 vaccine in birds."

Live vaccines offer important advantages, Halvorson explained. One is that they require less antigen (active ingredient) than killed vaccine. A live vaccine may contain too few copies of the weakened virus to trigger an immediate immune response, but once inside the host, the virus replicates to the point where the immune system detects and responds to it. A killed virus must be injected in larger doses, because it doesn't multiply inside the recipient.

A second advantage is that live viruses don't have to be injected into each bird individually; they can be put into drinking water or sprayed into the air in a chicken coop. That way, hundreds or thousands of birds can be immunized quickly. Killed viruses, by contrast, must be injected, because there's no other way to administer them that will bring them into contact with the immune system.

Earlier this week, not long after Halvorson predicted that live vaccines would be used against H5N1, Chinese veterinary officials announced they had developed a live-virus vaccine covering both H5N1 flu and another devastating poultry virus, Newcastle disease.

In a follow-up interview, Halvorson said it appeared that the Chinese vaccine involved a genetically engineered Newcastle disease virus, rather than a live influenza virus. "I believe they're talking about a recombinant Newcastle vaccine virus that will express a protein from an [H5N1] influenza virus, and the body would produce antibodies against that H5 virus," he said.

"A similar thing was done here [in the United States] a few years ago," but it didn't lead to a marketable vaccine, he said.

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<B><font size=+1 color=red><center>Panafrica Faces Bird Flu, Pandemic With Special Challenges</font>

United States Department of State (Washington, DC)

December 22, 2005
Posted to the web December 31, 2005

Charles W. Corey
Washington, DC
<A href="http://allafrica.com/stories/200512310152.html">allafrica.com</a></center>
As the world faces the further spread of avian influenza and the possibility of human pandemic influenza, Africa will encounter special challenges preparing its own defense, says development economist Asif M. Shaikh, president and chief executive officer of the International Resources Group (IRG).</b>

Rapid mobilization is most needed to fight a possible bird flu outbreak among animals, in order to prevent escalation into a human disease pandemic, Shaikh told the Washington File December 13. Broadly speaking, he said, a direct response requires attention to four key areas: awareness, capacity building, prevention and mitigation.

"When you compare those four needs to Africa's capabilities," he said, "the first finding is Africa has a very weak infrastructure" both institutional and physical. "So it is going to be a challenge to build response systems quickly enough. A great deal depends on if and when" pandemic may occur, he said.

Avian influenza is an animal infection caused by influenza (flu) viruses. These influenza viruses occur naturally among birds. Wild birds worldwide carry the viruses but usually do not get sick from them. However, avian influenza is very contagious among birds and can make some domesticated birds, including chickens, ducks, and turkeys, very sick, sometimes fatally.

The H5N1 virus is just one strain of avian influenza, but a dangerous one because of its proven capability to infect humans and its potential to cause a pandemic. The World Health Organization has documented almost 140 human cases of H5N1 infection since January 2004. Most of these cases have occurred as a result of people having direct or close contact with infected poultry or contaminated surfaces.

Of the few avian influenza viruses that have ever crossed the species barrier to infect humans, H5N1 has caused the largest number of detected cases of severe disease and death in humans, according to the U.S. Centers for Disease Control and Prevention (CDC).

In Asia, H5N1 has caused the broadest outbreak of avian influenza among humans ever seen since its first appearance two years ago. Now the disease has moved west, appearing in flocks in Russia, Kazakhstan, Turkey, Croatia and Romania. Some experts predict that migratory flocks will carry the disease to African birds in their seasonal movements.

DISEASE DETECTION AFRICA

Shaikh, who has been professionally involved with Africa since 1972, explained that most poultry in Africa is raised on small farms or in remote villages, with 80 percent of Africa's poultry production being noncommercial.

"The ability to get the message to farmers on how to identify a sick bird in the first place is limited," he said, due often times to their remote location. "The capacity for farmers to do that identification and to get the information back to a relevant authority is limited" as well, he said, because of the region's poor communication infrastructure.

Hong Kong in one day slaughtered 1 million birds in an effort to contain and prevent a spread of the virus, he said. "That is not going to be possible in a dispersed situation in Africa -- so the containment capacity" will be limited there, he said.

The financial capacity to respond to a possible pandemic in Africa is another challenge, he said.

"Does Africa have the resources to mount a massive retaliation to contain," a pandemic, he rhetorically asked? Answering his own question, he said, "Containment will be a problem because it will be difficult to get those resources" on such a massive scale.

International donors now are planning how to expand laboratory and disease surveillance capabilities in developing nations so that they are better able to monitor animal diseases that could burst into human populations.

Another key issue to consider, Shaikh said, is that "relative to any other part of the world, African governments are very heavily dependent on donors for their finances, for their institutional capacity and their technical expertise. So to a large extent, Africa's response to avian flu will be influenced by what the international community supports as Africa's response to the avian flu.

"If we imagine a pandemic at a time when the whole world is preoccupied with its own situation rather than thinking about other parts of the world -- that could be negative for Africa. Part of the goal is to help assure that that does not happen because we are all in this together. It is a global issue. If it breaks out anywhere it can spread everywhere."

ONE BURDEN TOO MANY

Comparing a potential human influenza pandemic to what Africa already is enduring with regard to HIV/AIDS, Shaikh noted, "HIV/AIDS is â-oe chronic and â-oe continues to build with each year â-oe. It has a permanent long-lasting impact. Avian flu would be different," he added, as pandemic influenza typically unfolds in human populations over a period of a few years.

Shaikh again stressed however, that presently, "there is no certainty that we will have a pandemic."

Pandemic influenza would be similar to HIV/AIDS is that it could affect many of those same vulnerable populations who live in nations with chronic health problems and poor health care.

"The great danger is that this could affect Africa across the board and really exacerbate everything that HIV/AIDS has done," he said.

Modeling must be done, he said, if one is to try to understand the full potential impact that an influenza pandemic could have on Africa. "Africa loses a great deal of people already from â-oe malaria, infectious diseases, diarrheal diseases, HIV/AIDS, civil war, famine, so we have to understand it in the context of all of those things and assure that we have response strategies that are realistic and founded on what this thing might actually do and that work to protect Africa's economic growth.

"If we look 10 years out, if we do not protect economic growth," he speculated, "then we are more likely to have many, many more people die from the secondary causes" of pandemic influenza.

Summing up, Shaikh said, the most important thing to do to contain the spread of bird flu and prevent a human influenza pandemic is to help bring about a coordinated response. Multiple sectors would be involved, he said.

"This is fundamentally an environmental, economic and health problem, and so there needs to be a capacity to work across sectors and to coordinate responses" to confine the virus to animal populations and prevent its crossover into humans.

Shaikh noted that it is fortunate that a large number of agencies of the U.S. government already are involved in mounting a response to a possible influenza pandemic: the U.S. Department of State, CDC, the U.S. Agency for International Development (USAID) and the U.S. departments of Defense and Agriculture.

"Coordinating that response is going to be one of the biggest challenges this country (the United States) faces â-oe. so response coordination is probably the most important thing we are working on right now."

Shaikh said the United States already has "tremendous capabilities" and "huge assets" on the ground in Africa that could help marshal a response in the event of pandemic influenza. That is especially important, he said, "Because to start from scratch â-oe would be a terrible mistake."

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<B><center>U.S. tightens its borders in bird flu fight

Mike Madden
Republic Washington Bureau
Dec. 31, 2005 12:00 AM
<A href="http://www.azcentral.com/arizonarepublic/news/articles/1231border-flu.html">azcenterl.com</a>

<font size=+1 color=brown>WASHINGTON - The battle against bird flu is heading to the border.</font></center>
From exotic wild parrots to fighting roosters to run-of-the-mill frying chickens, hundreds of thousands of birds are brought into the United States each year. And the traffic is surprisingly heavy: Some years, birds rank second behind only drugs in cargo seized along the borders. </b>

Now, fear that a worldwide flu pandemic might start if an infection spreads from birds to people has federal health, agriculture and border protection officials stepping up efforts to find and stop anyone carrying the animals into the country. advertisement




Even healthy birds from countries with avian flu outbreaks are banned. Pet birds coming in through ports of entry are quarantined for 30 days to make sure they're healthy. And law enforcement agencies are raiding illegal bird markets and breaking up smuggling rings.

But for every bird caught, more are getting through, raising possible health concerns if even one carries avian flu.

"Much of what we're doing is to make sure that the animal element, the bird element, doesn't get into the country," said Leah Yoon, a spokeswoman for the Department of Homeland Security's Bureau of Customs and Border Protection, whose agents staff inspection posts at airports and land-based border crossings and track illegal entry elsewhere on the borders.

Southwestern border

Brian Levin, a U.S. Customs and Border Protection spokesman in Tucson, said port inspectors in Arizona occasionally see exotic birds such as parrots but typically do not find people smuggling poultry, which is generally considered higher risk for the avian flu.

On Wednesday, port inspectors in Nogales found two finches in the back seat of a vehicle. On Nov. 23, they confiscated two Amazon parrots hidden under a blanket.

"I expect we will probably see some more as people come back into the country after visiting (Mexico) for the holidays," Levin said.

Exactly how many birds are smuggled into the country is unclear because government agencies keep statistics only on how many are caught, and they don't estimate what fraction of the traffic they intercept.

Public health officials have worried for years about the possibility that flu could spread from birds to humans, sparking an outbreak of flu around the world that no one has natural immunity against. Infected birds have been found in Asia and Europe. One strain of the disease has killed more than 60 people in four countries, mostly those who handled sick birds.

The Bush administration has asked Congress for $7.1 billion to prepare for bird flu. About $9 million of that would go to help the Agriculture Department stop illegal bird imports.

Smuggling poses a particular challenge for flu prevention. Though there aren't any recorded cases of bird flu in Mexico or Canada, infected birds smuggled across the border may not be detected until they make other birds sick.

Bird collectors could use smugglers to bring in exotic species, circumventing import bans on endangered animals or avoiding customs duties and quarantines.

But that's not the only possible threat. In some cities with large immigrant populations, live poultry markets slaughter chickens, turkeys, ducks and other birds without direct oversight from Agriculture Department regulators, who leave small operations to state monitoring.

In the Southwest, fighting roosters are smuggled in frequently from Mexico, despite bans on cockfighting in every state but Louisiana and New Mexico.

The Southwestern border is a particular focus because most birds seized from smugglers come from Mexico. In fiscal 2004, agents seized 348 birds along the U.S.-Mexican frontier, according to Customs and Border Protection. The next year, they caught 504.

Those numbers don't include shipments stopped at official ports of entry that contained birds or bird parts from flu-affected countries. Statistics on those seizures are classified, officials said.

"If I had one wish to improve the situation, I would like to get increased staffing for inspections at ports of entry and at the borders to try and detect clandestine importations," said Paul Arguin, acting chief of the Centers for Disease Control and Prevention's geographic medicine branch.

In the past few months, Agriculture and Homeland Security agents have seized thousands of pounds of frozen poultry from China, Thailand and other countries with bird flu outbreaks, despite a ban on such imports.

Poultry smuggling

Most birds brought into the country illegally are taken secretly through legal ports of entry, said Simon Habel, director of Traffic North America, a wildlife trade-monitoring network based in Washington, D.C.

Crackdowns at airports in San Francisco, Los Angeles and Seattle may have helped keep birds from Southeast Asia out of the United States, but the increased security could send smugglers to airports in Canada or Mexico, hoping to bring birds over porous land borders.

"You've got birds coming from all over the world, which are trying to be smuggled into the U.S. on a regular basis," Habel said. "It only takes one bird to come in and get in contact with other birds."

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<B><font size=+1 color=green><center>China Confirms Additional Human Bird Flu Infection H5N1</font>

Category: Flu/Bird Flu/SARS News
Article Date: 31 Dec 2005
by: Christian Nordqvist
Editor: Medical News Today
<A href="http://www.medicalnewstoday.com/healthnews.php?newsid=35592">medicalnewstoday.com</a></center>
Chinese authorities have confirmed that a woman, 41, died of bird flu infection (H5N1 strain) on December 21. She was from Fujian, South East China. On December 6th she developed a fever and pneumonia and was taken to hospital on December 8th. </b>

Initially, lab tests seemed to show she did not have avian flu virus strain H5N1 infection. However, subsequent tests, carried out on December 23rd, which included PCR tests, gave positive results. The latter tests were done at the Chinese Centre for Disease Control, Beijing. The virus was isolated from the patient.

The deceased woman's relatives and people who have been in close contact with her are under medical observation - authorities say none of them have displayed any symptoms of bird flu.

The H5N1 bird flu virus strain has not been found among poultry near to where the woman lived and worked. Authorities say they cannot confirm whether she had any direct contact with live birds before she became ill. Experts from the Chinese Ministry of Agriculture are still investigating.

This is the seventh officially confirmed case of a human becoming infected with bird flu, H5N1 virus strain - three have died.

The following provinces (in China) have reported humans becoming infected with avian flu (H5N1):

- Anhui
- Fujian
- Guangxi
- Hunan
- Jiangxi
- Liaoning

(Bird Flu = Avian Flu)

The H5N1 virus strain of bird flu is the most virulent one (virulent = powerful, potent, dangerous)