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H5N1 Bird Flu Cluster in Garut Indonesia Grows to Three?
Recombinomics Commentary

August 15, 2006

The nine-year-old girl, Ai Siti Aminah, was from Cikelet in West Java's Garut district, said Wijayanti, a doctor from Garut's main hospital. It is the same area as a 17-year-old confirmed two days ago as infected with H5N1.

Wijayanti told AFP that the girl, who was from a different village to the teenager, was admitted to hospital on Monday afternoon with pneumonia.

"She was immediately taken to the isolation unit, had samples taken and then received treatment but her condition was already failing at the time. She remained unconscious until her death today," she said.

Seventeen-year-old Umar Aup was listed as Indonesia's 57th confirmed case of H5N1 on Sunday. Forty-four of those died, making the nation the world's worst-hit.

Another health official said Tuesday that a cousin of Aup had died showing symptoms of the virus more than a week ago.

Iman Firmanulah, the head of the contagious disease section of Garut's health office, told AFP that Aup's cousin Misbah died on August 6 exhibiting bird flu-like symptoms.

But 20-year-old Misbah was buried before samples were taken, he said.
"We cannot positively say that he died of avian influenza but he showed symptoms that were similar to those of bird flu patients," he said.

The above comments describe three suspect H5N1 bird flu cases in Garut in West Java.  Although H5N1 has only been confirmed in the only surviving member, the index case was the cousin of the H5N1 confirmed case and test results from the third member has not been released.  However, these three cases appear to be forming a geographical cluster in West Java.  These cases are in addition to the two confirmed fatalities in suburbs of Jakarta who also died with the past week.

Five new cases on Jakarta are cause for concern.  Although WHO updates cite contact with dead or dying poultry, the sequences released from the patients on Java do not match the poultry H5N1 sequences.  Recent bird samples are being tested in Australia, but the first set of samples released are from birds from Wates in northern Sumatra and are closer to the Karo cluster, although there are also significant differences in that group also.  However, those differences may be related to collection dates.  Currently, there are no public bird H5N1 sequences from 2006.

However, the Java cases have been reported for over a year, and all but one of the human sequences reported to date have the novel cleavage site, RESRRRKKR.  These isolates also have changes in all eight gene segments that do not match the poultry isolates.  Thus far the only match with the human sequences is with H5N1 from a cat in the Jakarta area..

The new cluster described above highlights the large number of cases in Indonesia, as well as the lack of testing in regions where there are poultry deaths.  Although poultry may not be the source of the human infections, they may signal H5N1 in an alternative reservoir.  Many or most of the cases without a link to dead or dying poultry would be missed, because H5N1 is tightly linked to this association.  Clusters such as the one in Garut however, raise the suspicion level which leads to more testing.

However, the lack of testing in humans as well as alternative reservoirs of H5N1 infections, such as swine, cats, dogs, and wild birds is cause for concern.

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