WHO: Avian influenza ? situation in Indonesia

[Harriet]

Avian influenza – situation in Indonesia – update 31

14 September 2006

The Ministry of Health in Indonesia has confirmed two additional cases of human infection with the H5N1 avian influenza virus. These cases occurred in March and May 2006.


The first case occurred in a five-year-old male from East Bekasi, West Java Province. He developed symptoms on 4 March 2006, was admitted to hospital on 6 March, and died on 19 March. Test results, using two different assays, showed high antibody titer for H5N1 on consecutive serum samples taken on days 11 and 15 of his illness. These test results are consistent with new WHO criteria for laboratory confirmation. A field investigation at the time found that the case was exposed to diseased poultry in the vicinity of his home, where some birds tested positive for the H5 virus subtype.

The second case is a 27-year-old male from Solok, West Sumatra Province. This case was identified during the tracing of contacts of the man’s sister, a 15-year-old female who developed symptoms on 17 May 2006 and was subsequently confirmed to be H5N1 infected. Her brother spent six days caring for her during her hospital stay. The brother developed mild symptoms of cough and abdominal discomfort, with no fever, on 28 May 2006; his symptoms remained mild and he recovered within a few days.
Despite his mild and atypical symptoms, the brother was tested as part of the Ministry of Health’s protocol for contact tracing and the management of any contacts with symptoms. He was given a five-day course of oseltamivir beginning on 1 June and was placed in voluntary isolation pending recovery.

Initial tests of samples collected from the 27-year-old male were negative for H5N1 infection. In August, follow-up testing of paired-serum samples found a fourfold rise in neutralization antibody titer for H5N1, a test result which meets the WHO criteria for laboratory confirmation.

The 27-year-old male reported no contact with diseased or dead poultry in the days prior to symptom onset as he spent most of his time at the hospital. The investigation determined that he had exposure to his sister during her hospital stay, and that human-to-human transmission could not be ruled out as the source of his infection.
The retrospectively confirmed cases bring the total in Indonesia to 65. Of these cases, 49 have been fatal.

http://www.who.int/csr/don/archive/country/idn/en/

 

[Harriet]

Re: WHO: Avian influenza ? situation in Indonesia

Perhaps someone can help me. Cannot find any record of the 15 year old sister's death ever being reported on the WHO website. Also there is no link to diseased poulty.

At least they are being more forthcoming with cases that previously fell through the cracks.

2 things concern me, the timeliness of these reports and the number of familial clusters that have been occuring for some time. Cases under investigation now may not be reported until sometime next year.

 

[Laidback Al]

Re: WHO: Avian influenza ? situation in Indonesia

<TABLE cellSpacing=0 cellPadding=6 width="100%" border=0><TBODY><TR><TD class=alt2 style="BORDER-RIGHT: 1px inset; BORDER-TOP: 1px inset; BORDER-LEFT: 1px inset; BORDER-BOTTOM: 1px inset">Avian influenza ? situation in Indonesia ? update 15
29 May 2006
The Ministry of Health in Indonesia has confirmed an additional six cases of human infection with the H5N1 avian influenza virus. Three of these cases were fatal.
None of the newly confirmed cases is associated with the family cluster in Karo, North Sumatra. The cases are widely dispersed geographically (see map below).
One newly confirmed case is an 18-year-old man from East Java Province. He developed symptoms on 6 May and was hospitalized on 17 May. He is now recovering. The investigation found a history of exposure to dead chickens in his home within the week prior to symptom onset. No further cases of influenza-like illness have been identified during the investigation and monitoring of his close contacts.
Two additional cases occurred in a 10-year-old girl and her 18-year-old brother from Bandung, West Java. Both children developed symptoms on 16 May, were hospitalized on 22 May, and died on 23 May. Both children had a history of close contact with sick and dying chickens at their home in the week before symptom onset. The identical onset dates strongly suggest that they acquired their infection following a shared exposure to poultry, and not from each other. Follow-up of contacts has not identified further cases of influenza-like illness.
An additional case occurred in a 39-year-old man from West Jakarta. He developed symptoms on 9 May, was hospitalized on 16 May, and died on 19 May. The investigation determined that the man cleaned pigeon faeces from blocked roof gutters at his home shortly before symptom onset. No further potential source of exposure was identified.
The remaining two patients are a 43-year-old man from South Jakarta, who developed symptoms on 6 May, and a 15-year-old girl from West Sumatra, who developed symptoms on 17 May. The 43-year-old man has recovered and been discharged from hospital. The 15-year-old girl remains hospitalized. The sources of exposure for these two cases are under investigation.
The newly confirmed cases bring the cumulative total in Indonesia to 48. Of these cases, 36 were fatal.


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http://www.who.int/csr/don/2006_05_29/en/index.html<!-- / message --><!-- edit note -->

Information on the 15 year old girl.


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[Harriet]

Re: WHO: Avian influenza ? situation in Indonesia

Thank you. Did not realize she was part of the cluster.

 

[Laidback Al]

Re: WHO: Avian influenza ? situation in Indonesia

It is a cluster now with the brother confirmed. It wasn't a cluster in May. Too many retrospectively confirmed cases.

 

[HenryN]

Re: WHO: Avian influenza ? situation in Indonesia

Perhaps someone can help me. Cannot find any record of the 15 year old sister's death ever being reported on the WHO website. Also there is no link to diseased poulty.

At least they are being more forthcoming with cases that previously fell through the cracks.

2 things concern me, the timeliness of these reports and the number of familial clusters that have been occuring for some time. Cases under investigation now may not be reported until sometime next year.

The number of "confirmed positives" is heavily dependent on the case definition. The definition in the past was tilted heavily away from false positives and generated many false negatives because the testing was not realistic.

The index case for Indonesia is a good, but not unique, example. Initially the hospital did not collect samples for testing (or improperly collected samples). By the time the patient's blood was tested, there titer was 320 and was a screaming positive. Hong Kong and the CDC ran the test and both got a screaming positive. A second serum collection was made three days later and the titer rose to 640. Both labs measured the increase, so the patients was a screaming positive in four of four serum tests. Her sister and father died with bird flu symptoms and her father was PCR positive by the CDC and Hong Kong, and both labs isolated and sequenced all eight genes of A/Indonesia/5/05. The virus was used as a target for a pandemic vaccine.

However, until last week his daughter was not a confirmed case because there was no early sample (which would have had low or no titer), and the later collections were only 3 days apart so there wasn't enough time between collections to allow for the titer to rise 4X.

Thus, two obvious positives were nit confirmed until last week, and the baby sister remains unconfirmed even though her father and sister are now confirmed cases.

The latest confirmed case is confirmed because two samples were collected and tested. I suspect two collections and tests are rare. My guess is the nurse with symptoms after caring for Karo or Jakarta patients were not tested twice for neutralizing antibodies.

"Forthcoming" and "confirming" are largely defined by interest levels, not H5N1 levels.

 

[Harriet]

Re: WHO: Avian influenza ? situation in Indonesia

Indonesian Bird Flu Case May Have Spread Among People (Update2)

By John Lauerman

Sept. 14 (Bloomberg) -- A 27-year-old Indonesian man with bird flu may have caught it after spending six days caring for a sister hospitalized with the disease, the World Health Organization said.

The case brings the country's infections to 65 people, including 49 deaths, the United Nations health agency said on its Web site. The man, from Solok in West Sumatra, developed mild symptoms in May and recovered in a few days.

An investigation ``determined he had exposure to his sister during her hospital stay, and that human-to-human transmission could not be ruled out as the source of his infection,'' the agency said in a statement today. He reported no contact with dead or diseased poultry before falling ill.

The case represents another instance of possible human-to- human transmission and raises questions about the strain of H5N1 spreading in Indonesia, said Ira Longini, a University of Washington epidemiologist who advises the U.S. government on flu issues. Health officials are concerned that the H5N1 bird flu, which has killed more than half of those infected, may mutate into a form that spreads easily among people.

``It's still an avian strain, but it could be more adapted to human populations,'' Longini said today in a telephone interview. ``These human clusters of cases in Indonesia with apparent human-to-human transmission are great cause for concern.''

Initial Tests

The man's initial tests for H5N1 were negative, the WHO said. Follow-up testing of his blood showed a significant increase in antibodies to the H5N1 virus, which met the agency's criteria to confirm the infection.

Disease trackers investigated another outbreak of bird flu among Sumatran family members in May, in which a woman might have passed the infection along to six relatives. One of those patients, a 10-year-old boy, may have then infected his father.

The H5N1 flu has infected 246 people in 10 countries since late 2003, killing 144 of those patients, the WHO said today. More than 200 million birds worldwide have died from the disease or been killed to prevent its spread.

Health officials in the U.S. and other nations have built stockpiles of antivirals such as Roche Holding AG's Tamiflu and GlaxoSmithKline Plc's Relenza. Roche said today that its U.S. supply chain for Tamiflu is fully operational and able to make treatments for 80 million influenza cases.

To contact the reporter on this story: John Lauerman in Boston at jlauerman@bloomberg.net .

Last Updated: September 14, 2006 15:15 EDT

http://www.bloomberg.com/apps/news?pid=20601080&sid=ajSTKABq2AL0&refer=asia

 

[Harriet]

Re: WHO: Avian influenza ? situation in Indonesia

The brother developed mild symptoms of cough and abdominal discomfort, with no fever, on 28 May 2006; his symptoms remained mild and he recovered within a few days.Despite his mild and atypical symptoms, the brother was tested as part of the Ministry of Health?s protocol for contact tracing and the management of any contacts with symptoms. He was given a five-day course of oseltamivir beginning on 1 June and was placed in voluntary isolation pending recovery.
Initial tests of samples collected from the 27-year-old male were negative for H5N1 infection. In August, follow-up testing of paired-serum samples found a fourfold rise in neutralization antibody titer for H5N1, a test result which meets the WHO criteria for laboratory confirmation.

Am surprised by the lack of reliability of these initial tests. You hear a lot about these real time tests used to diagnose people immediately. As more cases emerge can start to see patients varying severity and prognostic types.