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The confused jumble of media and medical reports coming out of Mansera, Pakistan is beginning to stabilize.  With that stabilization, we are beginning to get a picture of activity that is much more serious than originally assumed.

First, massive tips of the cap: The Flusites are absolutely nuclear with activity on this topic right now, with Flu Wiki and Flutrackers leading the way (you can click a link to them via this Website).  Dr. Henry Niman at recombinomics.com is doing his usual excellent job of sorting through the maze and reading between the lines.  Plus, all the A-list flubloggers -- Mike Coston, Crawford Kilian, SophiaZoe and others (just a click away via this site) -- are maintaining excellent lines of communication.

Distilled from all these sites and opinions and translations, here is what apparently has happened:

In one of the numerous Pakistani H5N1-related bird culls of the past few months, a veterinarian appears to have been exposed to the H5N1 avian flu virus last October.  Remember that date. He then, by all appearances, transmitted the virus to one or more of his brothers.  They died ten days apart, strongly suggesting a chain human-to-human transmission, precisely because of the lag times.  If the two sons were infected by, say, eating a diseased chicken at the same dinner table, or even as leftovers, the infection incubation period -- and therefore the deaths -- would have occurred much more closely together. 

But they didn't, and the timetable gets really scary here.  If the vet brother (A) gets infected in October during the cull, and one brother (B) dies on November 19 and the other brother (C) on November 29, there is reason to strongly suspect the infections were passed down like a daisy-chain.  Human to human.  Chain transmission. 

The next wrinkle is really something.  There was another brother (D) of the vet, and who is a resident of -- drum roll, please --  the United States!  He gets the word that brother B died November 19th, and goes home to Mansera, Pakistan.  He then manages to contract bird flu himself and tests positive for the disease.  After hospitalization and confirmed recovery, he returns to the Long Island, New York area.  Immediately upon his arrival at the airport in Nassau County, New York, local health authorities and the CDC immediately place him (D) in quarantine and test him thoroughly until it is determined he tests negative for H5N1 and is now safe to release.  Kudos to the CDC and the authorities in Nassau County, New York.  So the CDC can find people now!  That is a comforting fact.

So to recap: Four brothers (ABCD) are in the first cluster family, one a vet.  And that vet was, by newer media accounts, the sole person to expose himself to poultry during the cull.  Two brothers are now dead, and the remaining two have tested positive for H5N1.

At the same mass bird cull that the veterinarian attended, a day laborer also contracted H5N1.  He is in hospital.  the culler's daughter is either in the hospital with bird flu-like symptoms or simply under observation, depending on the accounts.  Family contacts of all infected are under observation and, one would hope, also under isolation.  .So a second potential cluster develops from the same cull.

All this sounds eerily similar to the outbreak of highly pathogenic H7N7 in the Netherlands in 2003.  As you recall, a veterinarian died in that outbreak, and human-to-human transmission was thoroughly documented by medical researchers (http://www.eurosurveillance.org/em/v10n12/1012-222.asp).  That study's abstract concluded:

Further seroprevalence studies among contacts of asymptomatic H7 cases should be conducted.

So we have as close to a confirmed familial cluster of H5N1 that we have witnessed since May, 2006 in Indonesia.  And we have another potential familial cluster with the culler/laborer.  There may be a third cluster, but I believe we are seeing the "fog of war" syndrome as the Pakistani press tries to sort out some erroneous and conflicting dates and test results.

Anyway, if we have two clusters or three, that is two to three too many for the Pakistani government to tolerate.  So today, the entire nation of Pakistan went on medical alert.  In a scene that reminds me of the end of Howard Hawks' classic The Thing from Another World, when the call "Watch the skies!  keep looking, keep watching the skies!" goes out via the wireless all over the world, local health departments in Pakistan are especially tasked with reporting ANY "untoward" situation.  They are clearly worried that, on this farm in Pakistan last October, Qinghai H5N1 (Clade 2.2) may have developed the capacity for efficient human-to-human transmission.

This should not surprise anyone in the least.   Who knows how many times since 2003, culling has prevented (or postponed) the Next Pandemic?  Go back to December, 1997, when then-Hong Kong health officer Dr. Margaret Chan may have saved the planet from a pandemic when she ordered the death of every bird in the city? At the risk of a bullet in the back of the head from her brand-new Communist Chinese handlers (Hong Kong passed from British to Chinese control in June, 1997), she made the decision to defy the totalitarian leaders and tell the truth.  As we know today, she runs the WHO.

I personally believe that the mutations necessary to change H5N1 to a lethal and efficient killer of humans can take place in multiple environments in multiple areas of the world at the same time.  These simultaneous "tipping points" are why we need to look at the Big Picture, rather than become focused merely on one flashpoint.  If chain H2H is happening in Pakistan, then right now, anywhere else on the planet H5N1 causes an outbreak in poultry, we now need to be extremely vigilant in our search for the presence of human clusters.  Everywhere.