After a six-month lull, five Egyptians were reported with H5N1, the viral strain causing highly pathogenic avian influenza (HPAI) during December 2007. Four of the patients subsequently died within just 7 days. All five cases occurred in the northern Nile Delta region amongst women who had contact with infected domestic poultry. Total number of cases in Egypt now stands at 43 with 19 fatalities.

According to MENA (Egyptian State news agency) and Reuters, the H5N1 virus tends to lie dormant during the summer and Egyptian officials hoped that, after two years of outbreaks, it would not recur this winter. However, WHO official John Jabbour expressed no surprise at the new cases. “The agent is there,” he said. “Since July we've had no human cases and things calmed down, so people returned to dealing with live birds as usual. Since the virus is there, we expect to have human cases. It's not a surprise at all.”

MENA recently reported a cull of 12,000 birds in Sharquia governorate after tests found the flock was infected with H5N1. Around 34 million birds have been culled in Egypt since March 2006. According to a report in Afrique en Ligne, Egypt has redoubled efforts against the disease in poultry, starting 2008 with 2000 poultry culled in the upper Nile Delta region.

Most human cases had been in contact with infected household birds, primarily in northern Egypt where the weather is relatively cool at this time of the year. Despite brave attempts, Egypt’s government has extreme difficulty enforcing restrictions on movement and sale of live poultry. Its vaccination programme ran into trouble because if the difficulties of enforcing such measures in rural areas, despite the additional 85 million doses of vaccines procured. The net result continues to be one of the biggest ongoing cumulative culls of poultry anywhere in the world. Here is also the highest number of human cases and fatalities for any country outside of Asia.

H5N1 continues to strike down mostly young women and girls in Egypt because they traditionally tend backyard flocks. Around five million households depend on poultry as a main source of food and income and the government admits this makes it unlikely the disease can be eradicated.

In a statement released by MENA, Abdel Rahman Shahin from the Health Ministry called on people to stay vigilant and deplored relaxation of precautions. He reiterated previous calls to ban keeping poultry in towns and any transport of poultry between governorates without authorisation, as well as strengthening controls on where birds are raised and sold. He also warned people who develop flu-like symptoms not to deny they had been in contact with domestic fowl. This makes it more difficult for doctors to identify and treat the virus which leads to unnecessary deaths, claimed Mr Shahin.

Compared with other countries like Indonesia, the human survival rate in Egypt remains relatively high, currently standing at 56%. The government suggested this was due to superior medical facilities. However, a high proportion of those affected have been young children, and studies have shown that this group with less developed immune systems have a better chance of survival than young adults. H5N1 generally kills patients indirectly through the over-response of the patient’s own immune system, overwhelming the body, especially the respiratory system.

WHO’s Mr Jabbour told Reuters that high fatality rate in recent cases was likely due to a delay in diagnosis after patients and their family members denied exposure to infected birds.

Egypt's position on the Black Sea Migratory Flyway from northern Europe and western Asia into Africa and the common practice of keeping domestic fowl near living quarters have combined to make Egypt the country hardest hit by H5N1 outside of Asia.

Both FAO and WHO have recently cited Egypt as one of half a dozen countries about which they are particularly concerned about endemic H5N1.