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H5N1 Pandemic in Jakarta Indonesia
Approaches Phase 6

Recombinomics Commentary

September 18, 2005

MT, a seven-year-old girl, currently being treated at the Sulianti Saroso hospital in North Jakarta, tested positive on her blood test, but negative on the Polymerase Chain Reaction (PCR) test, said Minister of Health Siti Fadilah Supari as quoted by news portal

The minister nor other senior officials of the ministry could be immediately reached for confirmation.

The girl was previously treated at the Siloam Gleneagles hospital in Tangerang and was referred to Saroso on Sept. 14. The ministry was still waiting for the results of a second PCR test.

It was also investigating another suspected case, identified only as a family member of Rini Dina, the country's most recent confirmed bird flu fatality. The relative tested positive on the blood test and is currently suffering from flu-like symptoms, such as a fever and sore throat, which are also symptoms consistent with early stages of avian influenza.

"We are taking the patient to a hospital for observation as soon as the family approves," she said.

Siti added that there was a high possibility of other suspected cases and that the public must be vigilant against the spread of the disease. She declared that the country was already in the "third stage of bird flu" and although there had not been any reports of human-to-human transfer of the virus, she added that "it is just a matter of time."

The above comments suggest Indonesia is already at stage 4 or 5 and the pandemic is close to the final stage 6 which is defined by sustained human-to-human transmission.

Human-to-human transmission was clear in the initial family cluster, which involved 3 members of a family of a government auditor (38M).  His eight year old daughter was the index case, showing symptom on June 24.  The time gap between her symptoms and her 1 year old sister who developed symptoms on June 29 is a strong signal of human-to-human transmission.  Such a 5-10 day gap has been present in almost all familial clusters in Vietnam, Thailand, and Cambodia.  WHO however, has refused to acknowledge the virtual certainty of human-to-human transmission in all or most of those cases, which account for more than one third of  confirmed cases.  Instead WHO maintains that the vast majority of cases come from poultry, thereby contributing to more human-to-human transmission within families, which is clearly happening in Tangerang.

The WHO position is compounded by use of lack of lab tests or false negatives to exclude patients.  In the family of the auditor, only he is an official case because his PCR test was positive. There were only two serum samples from the index case and both were positive in tests by two independent outside labs (in Hong Kong and Atlanta).  There was no doubt that the child died from H5N1 bird flu, but since the serum samples were collected just three days apart, the rising titer (a sign of recent infection) had not risen four fold in the three days, so only the father was called a confirmed case.  This exclusion justified the repeated claims of "no evidence of human-to-human transmission", when in fact there was little doubt that the gaps in onset dates of June 24, 29, and July 2 indicated the index case infected her sister and father directly or indirectly.

The comments above indicate there is another familial cluster between the fatal case of the immigration officer and one of her relatives, who is also laboratory confirmed.  Both of these clusters are in families of government workers who would have little direct contact with poultry or pigs.  Moreover there are two neighbors with symptoms and the two familial clusters live in the same area of Tangerang, southwest of the center of Jakarta.

This concentration of fatal, lab confirmed H5N1 is the highest ever reported and is likely to represent a fraction of the human cases because there are no reports of infection in those most associated with poultry and pigs.

Sequencing data from the earlier familial cluster indicates there is no reassortment with human genes and the sequence is similar to sequences found in poultry in Java.  Since H5N1 is endemic to Indonesia and extremely limited testing in Tangerang found H5N1 in pigs, poultry, and a pet birdcage, the opportunity of infections from animals and humans is extremely high.

WHO has yet to issue a warning to family members caring for relatives with H5N1 infections, thereby contributing to the human-to-human spread, which has been clear since the beginning of 2004 in Vietnam.

Instead, words of assurance are issued to the press and official counts bury the human-to-human transmissions and maintain a pandemic stage 3 when clearly the level is at 4 or 5 and will soon be phase 6.

WHO's failure to inform is hazardous to the world's health.  H5N1 does not read press releases.  In evolves via recombination and acquisition of mammal polymorphisms, which increases the likelihood of efficient human-to- human transmission.

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