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Another H5N1 Cluster Denied in Indonesia
Recombinomics Commentary 12:36
May 21, 2008

According to Mahbud, last May 1 Rizki complained was sick. "His body was hot." Hands, fingertips and foot very blue, said the father. Fortune was carried to the Yakriza Clinic, Tanah Kusir. "His diagnosis typhus."

A legacy of Rizki, Istiqomah showed the similar sign. Appetite descended, the tip of the finger turned blue and breathless. Isti could be treated two nights in the Gandaria Hospital afterwards were given by reconciliation to the Persahabatan Hospital, Rawamangun. Love, medical help could not rescue the life of the girl.

Priyanti, the team's member of the control doctor of Persahabatan Hospital bird flu, said, Istiqomah positive was affected by bird flu. The girl suffered hot was accompanied by the cough and breathless. The "photograph toraks him also showed the sign" of "pneumonia," said Priyanti.

At this time RS Persahabatan was also treating Alamsyah, 26 years, the older brother Istiqomah.

"Gandaria still could not be classified as cluster bird flu because of his incident just had one case and casualties that was ascertained positive also only one person," Togi words.

The above translation describes another H5N1 cluster that has been denied in Indonesia due to a mis-diagnosis and a false negative.  The index case died with bird flu symptoms, including cyanosis in extremities.  However, he was diagnosed as having typhus and not considered a bird flu case.  His sister had similar symptoms, including cyanosis in extremities, but she was lab confirmed as H5N1 positive.  Recent reports indicate the H5N1 was confirmed by a second lab, so she is an official case.  A third sibling was hospitalized with symptoms, but declared H5N1 negative.

The cluster was then declared as a non-cluster because only one of the three siblings was confirmed.  This denial is the third in the last four confirmed cases in Indonesia.  In the earlier cases, one cluster involved a relative who died with respiratory problems, while the index case for the other cluster was mis-diagnoses with dengue fever.  The diagnosis of dengue fever was questioned in media reports, but a mis-diagnosis was denied.  The denial was accepted without question in a Promed commentary.

These denials of clusters has extended an under reporting trend that is widespread, but the denial of three cluster out of the last four confirmed cases is an H5N1 record.  In the 1918 pandemic the most frequent mis-diagnosis were dengue fever, typhoid, and cholera.  Indonesia has previous mis-diagnosed patients with dengue fever and typhus previous, which were subsequently lab confirmed as H5N1.  However, the specific denials of obvious clusters are new.

In addition to the cluster denials, confirmation of cases is also delayed.  One case described in local media has not been confirmed, and there is a cluster of five family members with symptoms, but typhus has again been mentioned, even though birds in the neighborhood died suddenly.

The increase in cluster denials in Indonesia is a cause of increasing concern.

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