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Growing Bekasi H5N1 Cluster Raises Transmission Concerns
Recombinomics Commentary 18:57
March 5, 2009

Fatal victim is R (5), resident of Karawang, West Java. Victim passed away on Wednesday (4/3) 21.00 at Mitra Keluarga hospital East Bekasi accompanied with fever and breathing difficulty symptoms.

Another victim who's under treatment is S (29) resident of Kemakmuran, Kelurahan Margajaya, Kecamatan Bekasi Selatan. S is now under treatment at Hermina hospital, Bekasi.

The above comments describe two more suspect H5N1 cases in Bekasi.  One of the victims (5F) died today, when the other (29F) is hospitalized.  The hospitalized case lives about a mile (see updated map) from one of the earlier Bekasi fatality (42F).  Media reports on the date of death indicate she either died in late February, or early January.  A death in January would suggest that this fatality is the case referenced in yesterday's comments from the Ministry of Health, as well as the fourth case linked to the UNICEF announcement.  In any event, there have been three Besaki cases that are clustered within a couple of miles of each other in or near the Delatan district in south Besaki, and this clustering raises concerns.

Although these cases have poultry links, the clustering of these cases may signal a more efficient transmission from the poultry to people.  Previously, almost all human isolates from the Jakarta area had the novel cleavage site RESRRKKR.  The recent phylogenetic tree in the WHO update on vaccines included four Indonesian cases from 2008, which continued to evolve along the branch contain the prior human isolates with the novel cleavage site.  This change was not detected in poultry isolates from 2005 or 2006, but in 2007 it began appearing in poultry, raising concerns that the sub-clade of 2.1 that was infecting humans was becoming more common in poultry.  The latest clustering in Bekasi may signal additional changes in poultry H5N1, leading to more efficient transmission to humans.

Release of 2009 sequences from these patients would be useful.

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