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4 Indonesian Health Care Workers with Flu-like Symptoms
June 6, 2006
Test results have now convincingly ruled out H5N1 infection in all four nurses.
Two of the nurses cared for siblings, a 10-year-old girl and her 18-year-old brother, who were hospitalized in Bandung, West Java, on 22 May and died the following day. Test results for both nurses are negative for H5N1 infection. One nurse was shown to be infected with a seasonal influenza A (H1N1) virus, which is now circulating widely throughout Indonesia. The second nurse experienced only mild and transient symptoms, but was tested urgently as a precautionary measure. Her test results were also negative for H5N1 infection.
The two additional nurses, who work at a hospital in Medan, North Sumatra, were involved in the care of confirmed H5N1 cases among members of an extended family from the village of Kubu Simbelang in Karo District. One of the nurses, a 34-year-old woman, experienced only mild symptoms and has subsequently tested negative for H5N1 infection. The second nurse, a 42-year-old woman, developed influenza-like illness on 1 June. Test results received today are also negative for H5N1 infection.
The above comments in today's WHO update are cause for concern. Although WHO comments indicate the health care workers are "convincingly" negative, convincing tests would require collection of serum 3-4 weeks after disease onset dates. Since at least two of the health care workers developed symptoms in the past week, appropriate samples would not be ready for antibody testing for another two - three weeks.
Moreover, the identification of seasonal H1N1 is an additional cause for concern. All human H1 isolates to date, including the 1918 pandemic strain have PB2 E627K. Dual infections with H5N1 and H1N1 could lead to acquisition of E627K via recombination. Therefore, determining the H5 antibody level in convalescing serum is important, even though the health care workers had mild cases.
The optimistic report by the WHO is clearly premature, and is cause for concern.
The tendency to focus on optimistic results is a concern and endangering lives. One of the most telling examples is the status of anti-viral resistance markers in the Medan H5N1 isolates, which are amantadine resistant. Instead of disclosing the resistance, the WHO update indicated the isolates were oseltamivir sensitive, and withheld the amantadine resistances. Moreover, when asked about the changes, WHO consulting sequencer Malik Peiris declined comment.
The withholding of important sequence changes, coupled with withholding of human H5N1bird flu sequences in Indonesia, is cause for concern.
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