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H5N1Bird Flu Exported to Indonesia from Hong Kong or India?

Recombinomics Commentary

July 13, 2005

A father and his little daughter have died at a hospital in the western Java town of Tangerang from suspected avian influenza, local media reports said Wednesday.

Iwan Siswara Rafei, a staff with the Supreme Audit Body (BPK), died at the Siloam Gleneagles Hospital Tuesday afternoon after showing bird flu symptoms, reported the Detikcom online news service.

His daughter Thalita Nurul Azizah died earlier Saturday with similar symptoms, it said. Another daughter Sabrina Nurul Aisyah, who was first detected with the symptoms, is still under intensive treatment at the same hospital, around 20 km south of Jakarta.

She suffers high fever and respiratory problems.

The reports were first released by Metro TV, which reported that the family suffered the disease after their trip to Hong Kong and India.

The above familial cluster of bird flu is of concern for many reasons.  Since a family of three has symptoms, human-to-human transmission is a major consideration.  In addition, the return from a trip abroad highlights the potential of H5N1 being just one flight away, as well as the possibility of spread via other passengers, assuming the family had been flying. If linked to International airports, it would be the first reported H5N1 transmission linked to air travel.

The report leaves many questions unanswered, but two deaths will likely spur intense investigation and a combination of epidemiological and genetic investigations should provide answers.

The first questions simply focuses on disease onset dates. If all three family members developed symptoms at the same time, then a common source is likely.  If disease onset dates were bimodal, the index case probably infected other family members.  Since the index case is alive, but two family members have died, the initial reports sound like human-to-human transmission within the family.

Symptoms usually appear 2-4 days after exposure, so the dates would help determine if the infection originated in India, Hong Kong, or Indonesia.  Since none of the three suspect areas have reported fatal human H5N1 cases recently, the potential for infection at airports cannot be excluded by the public data.

The epidemiological data can be supported by sequence data.  Although there are no reported H5N1 cases in India, the Qinghai sequences include those from bar headed geese migrating from India.  These sequences have the PB2 E627K polymorphism, which had not been previously reported and the sequences have an unusual constellation of genes with 3 related to Shantou sequences and 5 related to Hong Kong sequences.  Prior sequences from Indonesia also contain sequences unique to Indonesia and Indonesia has a confirmed positive poultry worker, although symptoms were mild.

If the infections are linked to travel, then the number of actual cases is likely to be significantly higher than the reported number.

Transmission linked to international airports is a considerable concern.

Media sources

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