Cluster in Indonesia still unresolved

We had hoped to have better information about the possible cluster of bird flu cases in remote West Java, but the situation remains murky and unresolved. Nothing especially reassuring has yet happened to ease the discomfort of health authorities regarding whatever is happening there, at any rate. Reporting by The Jakarta Post is typical:

A young boy with symptoms of bird flu was rushed to Garut hospital in West Java on Saturday, raising the official number of people suspected of having bird flu from Cikelet village to 10 and pushing health authorities to widen an investigation into a potential bird flu cluster.

The new patient, a five-year-old boy identified as R, is a resident of Rancamareme hamlet and the brother of a young girl also identified as R, who died two weeks ago after showing bird flu symptoms. No blood test was conducted on the girl to confirm that she had died of the disease.

Head of the West Java Health Office, Yudi Prayudha, said there were a total of 10 patients from five hamlets in Cikelet and Cigadog villages, located some 130 kilometers south of Garut city who had shown symptoms of bird flu. (The Jakarta Post)

Blood samples of about 40 contacts were said to have been obtained (for what purpose, it isn't clear, since evidence of H5N1 antibodies would not be epxected to appear so quickly). Several deceased cases were originally diagnosed as "typhoid" and no testing was done. There is now some question as to whether they were bird flu cases. Two other children were said to have negative PCR tests for H5N1 (we reported them in an Update to our previous post) but the tests are being repeated. This suggests there is reason to doubt the negative tests.

Not to worry, though. The ever unreliable Minister of Health, Siti Fadilah Supari assures us this does not represent a cluster. Her reasoning is given by a subordinate:

Meanwhile, Director General for Disease Control and Sanitation in the ministry I. Nyoman Kandun said that the Garut cases could not be categorized as a cluster case because it happened in separate places and was not simultaneous.

"It happened on different days and are far from each other," Kandun said on Saturday. (Xinhua)

This is either deliberately misleading or Nyoman Kandun doesn't understand the concept of clusters. Cases closer together in space or time (or both) are of interest only for what they can tell us about what is going on about disease transmission and occurrence. If many people are infected within a few days by a common source in a small geographic area (a time-space cluster) it could indicate a common source (e.g., poultry) infected with a virus that is passing more easily to humans. On the other hand, people falling ill a week or so apart might indicate person to person transmission if they have had direct or indirect contact with each other. Communicable disease travels on social networks.

Different days or different locations are not criteria that rule clusters in or out. Only good epidemiological investigative work can do that. Indonesia has been conspicuously bad at that kind of follow-up.

More like this

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There are reasonable and plausible suggestions that there may be other reservoirs for H5N1 than poultry. We have discussed it here numerous times, but we don't know although I certainly wouldn't rule it out. But the poultry reservoir is gigantic and probably the source of most human contact with…

"People falling ill a week or so apart might indicate person to person transmission, if they had direct or indirect contact with each."
This Indonesian cluster meets the conditions stated above. These infections go back at least 2 weeks. Today's reports from the cluster area state there are now 12 suspected cases; and during the last 24 hours a 4 year old girl, a 14 year old boy, and a 60 year old man have been admitted. The 4 year old girl is suffering from high fever and respiratory problems. Her sister passed away 2 weeks ago.
This is not the first human H5N1 cluster is Asia to meet the above described criteria. There have been many.
Therefore, does this imply there might already exist sustainable person to person transmission of H5N1 in Asia?

The brother, who is now ill with symptoms and is in hospital, is Risman (5). His sister was Rubiyah (13) and she died on Aug 1, three weeks ago.

Their brother was Misbah (20) -- the male cousin of CONFIRMED CASE, Umar (17). Misbah died on Aug 5. These two are the ones who reportedly fed dead chickens to dogs.

In addition, it's likely that at least one more sibling from this family has presented with symptoms and is being tested (see link to flutrackers discussion below).

Thus, Rubiyah, who died THREE WEEKS AGO, is most likely the index case for this fairly large family cluster which involves at least 4 or 5 (or more) cases (Rubiyah, Misbah, Umar, Risman and other?).

For a (lengthy) discussion, see here >>

Also >>

Text from original Indonesian news story:

"Sebelumnya, tiga korban lainnya, Misbah dan Rubiyah, keduanya kakak kandung Risman, dan Dea Amalia, 9, anak kandung Euis Lina, meninggal dunia. Saat itu, ketiga korban didiagnosa terkena radang typhus, namun menjelang kematiannya mengalami shock dan sesak nafas berat."

Machine translation ( ):

"Beforehand, three other casualties, Misbah and Rubiyah, both of them the full sibling Risman, and Dea Amalia, 9, the uterus child Euis Lina, died. At that time, the three casualties were diagnosed was affected by the inflammation typhus, but gazed at his death experienced shock and breathless difficult."

By Theresa42 (not verified) on 21 Aug 2006 #permalink

It takes 5 maybe 10 minutes to listen to the explanation any doctor can give about transmission of viruses from one source to (an)other one(s) and about clusters, to grasp the possibilities of H5N1 appearance in this Indonesian region. Any international article on these Indonesian ill people has Clusters now as a topic. Is this minister unattentive, narcissistic, does she have uneducated advisors or what? Does anyone know who pulls her strings?
This is bad PR, Indonesia.
Educated and well informed people are more valuable than faking and reassuring people. The newspapers of foreign countries are telling more about your national situation than you do. You might be cautious about unconfirmed cases, but I guess this is a display of contempt to all people who did take the trouble to read for some time about this very subject of H5N1 clusters.

I posted some of this earlier on a different thread but too late to get comments from Dr Niman-----
These cases have been traced to children feeding dogs sick or dead birds. How long after feeding the dogs did the children get sick? Is it possible that the dogs get the flu from the birds and the virus further adapts to humans via the mammalian vector(dog)?
Have samples been taken from the dogs in question and sequenced? This would seem logical and prudent to me since they may be asymptomatic carriers - another mammalian source. I am not an epidemiologist, but I would expect one of them to pursue this and report on it if only to dispel fears of viral adaptation and dogs(or cats) as carriers.
I read in one of the books on the Spanish flu that passage of a virus from person to person increases the virus' ability to adapt to the human species many fold, I think it was 40 times increases infectivity as much as a million times. Therefore every new cluster, especially the undiagnosed cases, has the potential to develop an ever more adapted virus. AND THIS PROCESS DOES NOT NEED ANOTHER, OLDER, ALREADY INFECTIVE HUMAN FLU VIRUS TO DO IT!

By warpedweaver (not verified) on 22 Aug 2006 #permalink

Maybe Indonesians should be instructed how to do the work. Where to get the tests? How to use them? What groups of people to test? Maybe the instructions should be so short and easy to read that even people in panic can understand them?