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H5N1 Misdiagnosis In Indonesia Hides H2H Transmission
Recombinomics Commentary 13:36
June 20, 2008
Sardikin Giriputro, director of the Sulianti Saroso Infectious Disease Hospital in Indonesia, told an infectious disease conference in Kuala Lumpur that misdiagnoses and the late administration of drugs were partially responsible for the high mortality rates.
'It (H5N1) is misdiagnosed initially as dengue, bacterial pneumonia, typhoid and upper respiratory tract infection because of similar clinical features (symptoms),' Mr Giriputro said.
In a bid to reduce the death rate, the Indonesian government has begun distributing Tamiflu to health centres in areas where H5N1 cases have occurred.
'When doctors see influenza-like illnesses and where there is evidence of contact with sick poultry, then they give Tamiflu (without waiting for laboratory results),' Mr Giriputro said.
The above comments further support the interpretation that the reduction in confirmed H5N1 cases in Indonesia this season is largely dependent on misdiagnosis and false negatives. The misdiagnosis describe above was also noted in a New England Journal report earlier this year, which was displayed in a table of initial diagnosis for H5N1 confirmed cases in Indonesia. Only 12% of the cases were initially diagnosed as avian influenza. The most common initial diagnosis was pneumonia (46%) followed by upper respiratory illness (27%), dengue (12%), and typhus (4%). Since this update on avian infleunza in humans was written by WHO consultants, it is clear that WHO is well aware of this problem. However, the WHO updates on confirmed H5N1 cases in Indonesia fail to mention that relatives of three of the last five confirmed cases died with a diagnosis of “lung inflammation”, dengue fever, and typhus. These relatives died within days of the H5N1 confirmed cases and represent clear H5N1 clusters that almost certainly involved human-to-human transmission (H2H).
H2H has been vigorously denied at the highest levels in Indonesia, and the WHO updates act as enablers for this dis-information. Although the growth of these clusters appear to be somewhat limited, analysis is difficult because of the more widespread use of Tamiflu, which lowers the H5N1 levels and leads to false negatives, especially in mild cases which may be contacts of the confirmed cases.
WHO has defended its position by saying that the H5N1 transmission in Indonesia has remained unchanged, but that analysis is based on the small number of reported cases. The statements from the highest levels in Indonesia on the effect of H5N1 on Indonesia’s image and the blackout on suspect and fatal cases do not support a transparent policy or aggressive testing of suspect cases. These policies support the silent spread of H5N1 in Indonesia, which is not being effectively monitored by current policies and practices in Indonesia and at the WHO.
The failures continue to be hazardous to the world’s health.
Recombinomics Paper at Nature Precedings