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Fifth H5N1 Case in Jakarta Indonesia

Recombinomics Commentary

September 17, 2005

The Indonesian ministry of health again examined the blood sample of a six-year-old child, only identified as MT, for likely being infected by avian influenza (AI), the ministry`s official said here Saturday.

I Nyoman Kandun, the ministry`s director general for disease control and environmental improvement, said his team was conducting a further examination on the blood sample of the child, currently treated at Sulianto Saroso Hospital here since September 14.

"The patient`s serological test has shown that the virus is Avian Influenza but the child`s PCR (Polymerase Chain Reaction) is negative," he said.

As a result of the negative PCR result, Kandun said his team would again conduct another PCR test.

MT was firstly hospitalized at Siloam Gleanegles in Tangerang district, Banten Province,

The above comments indicate that Indonesia has a fifth case of H5N1 bird flu.  Although additional PCR tests are being performed, and second serological test with a titer 4 fold higher than the first test would meet the WHO rigorous requirement for a confirmed case.  The one positive serological test would place the child in the probable category.

The child was admitted to the same hospital where Indonesia's first three reported fatal cases died.  The relationship of this case to earlier media reports on the fourth reported case remains unclear.  That case was in the same general Tangerang area, but was hospitalize at Bintaro International Hospital.  The suspect case associated with the fourth case has been described as a contact without symptoms, a neighbor with symptoms, and a six year old neighbor.  The above case would appear to be the six year old neighbor and the initial admission to Siloam Gleneagles Hospital would suggest that all cases are from the same area in Tangerang.

None of these patients have clear connections with H5N1 infected poultry or pigs, which are widespread in Tangerang.  These cases continue to raise questions about H5N1 infections in people most closely associated with poultry.  The sequence of the H5N1 from the first confirmed patient indicated that it was similar to H5N1 detected in from poultry in Java, which would also suggest additional unreported cases.

The limited testing of poultry and pigs, coupled with the large number of false negatives, raises serious questions about the number of people infected in Indonesia by human-to-human transmission.  Thus far only two of the first five cases have been PCR positive and sample collection has been remarkably poor.

Only one of the first three fatalities was a official case.  Although the index case was hospitalized for 17 days before she died, there were only two serum samples collected three days apart.  Thus, although both samples were positive for H5N1, they rising titer did not meet the WHO case definition for an acute H5N1 infection.  Similarly, the 1 year-old sister was also not reported to be H5N1 positive.

The lack of sample collection at major medical facilities in Indonesia's capital raises more questions on transparency.  Although there is some effort being made to investigate some cases, the overall testing of animals and people remains suspect.

The number of confirmed or fatal H5N1 cases in a small geographical Indonesia is the highest reported to date, but the surveillance raises serious questions about any meaningful interventions by the WHO.  The continued reporting clear false negatives in high profile cases remains as causes for concern.

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