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H5N1 Clusters and Denials Raise Indonesian Pandemic Concerns

Recombinomics Commentary 13:50
March 31, 2008

Kandun dismissed the possibility of more bird flu cases in the same family after the boy's brother died recently. Confirmed cluster cases raise concerns over human-to-human transmission. "It is not correct that there is a cluster in Subang," Kandun said, adding that the brother has died of dengue fever.

The above denial of an H5N1 cluster in Subang is cause for concern.  Both brothers were initially diagnosed as dengue fever.  However, since dengue fever is transmitted by insects, the likelihood of two fatal cases in the same family with distinct disease onset dates is remote.  Consequently, the second case was tested for H5N1 and was positive, strongly suggesting that the index case was also H5N1 positive and infected his brother.  The denial of the cluster by the director general of communicable disease control in Indonesia raises serious transparency problems, and is similar to denials of H5N1 in the first confirmed cluster in Indonesia, almost three years ago.  Those cases were initially said to have died from bacterial pneumonia, although the father was subsequently H5N1 confirmed, and the H5N1 from that patient is a target for vaccines directed to clade 2.1, the clade of H5N1 in Indonesia.

In addition to the death of a family member of an H5N1 confirmed case in West Java, a similar cluster has been reported in the local media in Sumatra.  H5N1 has been confirmed in a young child, but the recent death of a family member has not been reported in the English language press.  Similarly, the nurse who cared for one or both family member is in isolation with bird flu symptoms, raising concerns of a expanding cluster.

The two clusters above, as well as a third confirmed case, located in Bekasi, which is near the two brothers in West Java, raises pandemic concerns.  Although clusters in Indonesia are not new, the government denial of the cluster in West Java and the failure of the English press to recognize the cluster in Sumatra, raises concerns that the number of cases and clusters are significantly higher than the reported confirmed or suspect cases.

More information of testing in these two clusters would be useful.  Dengue fever claims raise concerns that additional H5N1 cases are being mis-reported.

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