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Spike in Fatal H5N1 Indonesian Cases Raises Concerns
Recombinomics Commentary 14:37
March 3, 2009

Krisnamurthi had little details about the latest deaths, saying only that two were siblings from the city of Bogor and the others were women from Bekasi and Surabaya.

Republika also reported on Tuesday that two more deaths from the disease occurred at the weekend near the capital Jakarta -- a 5-year-old girl from Depok, and an 8-year-old boy from Bekasi.

The above comments from wire reports describe 4 more confirmed H5N1 fatal cases near Jakarta and describe 2 more recent suspect fatal cases in the same general area.  However, additional local reports describe a fatal case in Tangerang, which was said to have been lab confirmed, suggesting that there are at least 7 fatal H5N1 infections in the areas surrounding Jakarta, which are in addition to the two fatalities reported for Tangerang and Bekasi last month.

Details on these cases are somewhat lacking because of the news blackout that delays reporting.  WHO generally follows with situation updates, but these updates come after Indonesian announcements and trail disease onset dates by weeks or months.

The familial cluster in Bogor was described in local media reports and the two sisters died in late January.  In addition, the patient in Surabaya also died in January, but paramedics linked to the hospital in Surabaya were reported as hospitalized in critical condition, raising concerns that the H5N1 confirmed fatal case directly or indirectly infected the paramedics (see updated map).

The recent seven confirmed or suspect fatalities follow the news blackout last year, which followed a series of additional clusters.  The announcement of the blackout was accompanied by claims that the lower number of confirmed cases was due to more rapid treatment.  However, the rapid treatment would not lower the number of infections, unless there was significant human to human transmission.  Collection of samples after the start of treat may low the number of lab confirmed cases because of a lower viral titer linked to treatment.  Rapid treatment could lead to a lowered cases fatality rate, but there is little evidence in the confirmed cases.  Historically the case fatality rate for human H5N1 in Indonesia is approximately 80%.  However, the rate for confirmed cases reported this year is 100% for the six cases, all of which were on Java.  Indeed, it has been over a year since a recovered H5N1 case was reported on Java.  Since that cluster in February of 2008, all 10 reported cases last year were fatal.  Thus, for Java the case fatality rate has been at 100% for all 16 of the most recent reported H5N1 cases.

This high case fatality rate strongly suggests that milder cases are not report, either because they test negative because of titers lowered by treatment, or they are not tested at all because they are misdiagnosed or self medicated at home, which has been described for many suspect cases.  Indeed, many of the fatal cases die within hours of being transferred to an infectious disease hospital after local treatment at home, clinics, or smaller local hospitals and fatally infected family members linked to lab confirmed cases have been misdiagnosed as having lung inflammation, dengue fever, or typhus.  The recent Tangerang case was diagnosed as dengue fever, and the recent Bogor case was diagnosed as having dengue fever and typhus prior to lung x-rays and reports of contact with dead or dying poultry, which then led to the H5N1 diagnosis.

The spike in H5N1 cases in the Jakarta area increases concerns that the number of H5N1 in Indonesia in general and the Jakarta area in particular, are markedly higher that the recently announced confirmed cases.

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