since 2006 , moh mandates that clinicians refer all persons with influenza - like illness ( ili ) and < 2-week history of poultry contact to 1 of 83 chest and fever hospitals ( i.e. , a category of referral hospitals ) throughout egypt ( technical appendix figure ) . persons meeting the ili case definition have fever > 38c and > 1 of the following : cough , dyspnea , sore throat , myalgia , and body aches . persons meeting the ili case definition are admitted , and respiratory samples are collected for influenza testing . technicians at 8 sentinel sites also collected daily respiratory samples from 2 patients meeting the ili case definition and from all patients admitted with severe acute respiratory infection , defined as hospitalization occurring within 2 weeks of onset of fever and cough . nasal and oropharyngeal swabs were transported to egypt s national influenza center for testing by reverse transcription pcr ( 2 ) . for patients testing positive for h5n1 , moh staff visited their households ; administered a standardized questionnaire to obtain demographic , exposure , clinical , and treatment information ; and searched among patient contacts for additional case - patients . we obtained surveillance data collected during 20062015 and compared case - patients with h5n1 virus infection for november 2014april 2015 to those reported in previous years . we obtained the average epidemic period by calculating the proportion of samples testing positive for h5n1 each month throughout the period ( 4 ) . an epidemic was defined as consecutive months having a proportion of h5n1-positive samples that exceeded the annual july  june median .   during march 20 , 2006april 20 , 2015 , a total of 342 persons with h5n1 virus infection were identified in egypt ( figure ) . annual epidemics typically occurred during november  april , when 299 ( 87% ; 95% ci 84%91% ) of the 342 h5n1 illnesses occurred , resulting in a median of 23 case - patients ( interquartile range [ iqr ] 1331 ) per epidemic . of the total 342 case - patients , 165 were identified during 201415 , including 6 clusters of 23 case - patients . although this season had a higher number of case - patients than previous years , other seasons had higher proportions of h5n1 detections or clusters among samples tested . the median percentage ( 5.4% ) of monthly h5n1 detections among humans sampled during november 2014april 2015 was statistically similar to the median percentage ( 2.9% ) for march 2006october 2014 ( kruskal - wallis test ; p = 0.5 ) . the proportion of clustered case - patients was also similar for the 2 periods : 12 ( 7.3% ; 95% ci 3.3%11.2% ) of 165 case - patients during 201415 and 12 ( 6.8% ; 95% ci 3.110.5 ) of 177 case - patients during 20062014 . the number of human h5n1 case - patients identified each month was highly correlated with the number of h5n1 poultry outbreaks identified each month during 20062015 by the ministry of agriculture in the same communities ( r  =  0.3 , p = 0.002 ) . number of human respiratory samples tested , number of samples testing positive for influenza virus a(h5n1 ) , and proportion of positive samples , egypt , march 2006may 2015 . the case - patients identified during 201415 were characteristically similar to those from previous seasons . similar percentages were found to be women ( 100/165 [ 61% ] for 201415 ; 105/177 [ 59% ] for 20062014 ) , homemakers ( 50/164 [ 30% ] for 201415 ; 46/177 [ 26% ] for 20062014 ) , and poultry farm workers ( 2/165 [ 1% ] for 201415 ; 0 for 20062014 ) . case fatality rates were also similar : 51 ( 31% ) deaths among 165 case - patients during 201415 versus 64 deaths ( 36% ) among 177 case - patients for march 2006october 2014 ( p = 0.3 ) . almost all ( 163/165 ) case - patients during 201415 had exposure to domestic poultry 12 weeks before symptom onset ; 58% were involved in breeding , 24% in slaughtering , and 21% in preparing poultry . most ( 115/165 [ 70% ] ) were exposed at home ; 4% recalled exposure in shops , 3% at live bird markets , and 1% at farms . although 35% recalled exposure to dead birds and 19% to ill birds , 35% recalled exposure only to birds that appeared healthy . case - patients identified in 201415 were admitted and received oseltamivir treatment a median of 4 ( iqr 27 ) days after symptom onset . sixteen percent had preexisting medical conditions : 8 ( 5% ; 95% ci 2%8% ) had chronic chest illnesses ; 5 ( 3% ; 95% ci 0.3%6% ) had cardiovascular disease ; 5 ( 3% ; 95% ci 0.3%6% ) had diabetes ; 2 ( 1% ; 95% ci 0%3% ) had renal failure ; 2 ( 0.1% ; 95% ci 0%3% ) had liver failure ; and 1 ( 0.6% ; 95% ci 0%2% ) was obese . most case - patients had cough ( 87% ) and dyspnea ( 72% ) during their illness . as of july 2015 , of the 165 case - patients , 114 ( 69% ) had survived and 51 ( 31% ) died . survivors were younger than decedents ( median age 16 [ iqr 336 ] vs. 33 [ iqr 2043 ] years ; p = 0.0001 ) . oseltamivir treatment was begun within a median 4 ( iqr 26 ) days of symptom onset for survivors , compared with a median 5 ( iqr 37 ) days for decedents ( 2-sided wilcoxon rank - sum test ; p = 0.07 ) . our analyses suggest that h5n1 infections have recurred annually in egypt during november  april . although moh identified an unprecedented number of h5n1 case - patients during 201415 , the proportion of persons testing positive was similar to proportions of previous epidemic seasons . during 20062015 , the ministry of agriculture identified 3,273 outbreaks among poultry , primarily during egypt s november one study found that 2% of egyptians exposed to poultry were seropositive for h5n1 virus ( 5 ) . the large number of h5n1 case - patients identified during 201415 could result in part from increased respiratory sampling in communities with poultry outbreaks , rather than from marked changes in the virus s transmission characteristics . the h5n1 case - patients during the 201415 season had similar characteristics to those of previous seasons ( 6 ) . active surveillance from 20102012 suggests that 8% of healthy - appearing poultry in egypt were infected with h5n1 clade 2.2.1 ( 8) , yet only 1 case - patient in 201415 reported using personal protective equipment . human h5n1 infections have been shown to occur during poultry outbreaks , overlapping with october  december influenza epidemics ( 4 ) . egypt currently recommends seasonal influenza vaccination among health care workers , pregnant women , persons with chronic diseases , and hajj and umrah travelers . countries where seasonal influenza overlaps with h5n1 circulation in poultry might explore the feasibility of vaccinating persons at high risk for influenza co - infections and complications ( 9 ) . this strategy perhaps enriched the number of h5n1 case - patients identified during peak epidemic months , compared with randomly selecting persons meeting case definitions for respiratory illnesses . although we did not find increased rates of persons testing positive for h5n1 , all h5n1 case - patients are unlikely to have the same probability of being identified ( i.e. , contacts vs. randomly selected persons ) . although the characteristics of case - patients during 201415 were similar to those of previous seasons and do not suggest increased efficiency of h5n1 transmission between humans , moh would be warranted in examining h5n1 virus circulating in egypt for genomic markers of mammalian adaptation ( 10 ) , which have been identified since 2010 ( 11 ) , and in using a cross - sectoral approach to evaluate interventions to prevent h5n1 infections . technical appendix . figure showing locations of human cases of influenza virus a(h5n1 ) infection , clusters of cases , and chest and fever hospitals where case - patients were treated , egypt , november 2014april 2015 .
during november 2014april 2015 , a total of 165 case - patients with influenza virus a(h5n1 ) infection , including 6 clusters and 51 deaths , were identified in egypt . among infected persons , 
 99% reported poultry exposure : 19% to ill poultry and 35% to dead poultry . 
 only 1 person reported wearing personal protective equipment while working with poultry .