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Increasing Human to Human Transmision of H5N1 in Jakarta
September 20, 2005
About the government`s decision on Monday to declare the outbreaks a National Extraordinary Happening (KLB), the minister said it was intended to make the public throughout the country alert to the disease.
"Besides, previously there was only one danger point, namely Pak Iwan Siswara but now there are two more danger points, namely RD and MG," she said.
The above "danger points" refer to three individuals who appear to be transmitting H5N1 to other people. The efficient human-to-human transmission is the major area of concern with regard to a catestrophic flu pandemic. H5N1 appears to be getting more and more efficient at such transmissions.
This transmission results in infections via casual contact and is becoming clearer at the Ragunan Zoo where three zoo employees have symptoms as well as in Tangang where the three human-to-human clusters are clustering.
The initial danger point was Pak Iwan Siswara who was a government auditor who died from H5N1. He is cited because he is the only member of his family listed as an official H5N1 case, but the index case was his 8 year old daughter, Sabrina Nurul Aisyah who developed bird flu symptoms on June 24. She is not listed as a confirmed case because there were only two serum samples collected and they were collected just 3 days apart so although both samples were positive and the antibody level was higher in the second collection, the increase was not 4 fold, which is the WHO standard, although that rise is expected in samples collected with longer time intervals between collections. Sabrina's 1 year old sister, Thalita Azizah, developed bird flu symptoms on June 29, but she died on July 9, so again she was not confirmed because of the lack of samples. Sabrina's father did not develop symptoms until July 2 and samples were collected at the appropriate time and he was PCR positive for H5N1. All three died within 5 days of each other, between July 9 and July 14 at Siloam Gleneagles Hospital in Tangerang. The onset dates strongly suggested that Sabrina infected her 1 year old sister and then one of the sisters infected their father.
Between this cluster and the current clusters, there were 20 suspect cases who tested negative. However, if view of the limited number of samples collected in the first cluster, false negatives cannot be easily ruled out.
The new series of clusters began with RD who was Rita Dina, Indonesia's second confirmed H5N1 case. She developed symptoms on August 31, was hospitalized on September 6 and died September 10. Although she lived in the same general area as the earlier cluster, she also lived 100 meters from a chicken slaughterhouse. At the time she developed symptoms, a 2 month-old boy, Livo Rustini (LR), died of pneumonia. He had bird flu symptoms and lived above a chicken slaughterhouse, which may have bee the same slaughterhouse 100 meters from Rita Dina's home. If not, the two slaughterhouses were near each other, because Livo's mother was interviewed while waiting in line for tests being offered to neighbors of Rita Dina.
A more direct connection with Rita Dina was her nephew who also tested positive for H5N1. The nephew has also recently developed symptoms and is currently hospitalized.
Media reports indicated that one of Rita Dina's neighbors also had bird flu symptoms and was hospitalized. This neighbor was probably a 6 year old girl with initials MG. MG was also from Tangerang and also tested positive for H5N1. She was initially hospitalized at Siloam GlenEagles Hospital in Tangerang and subsequently transferred to the Sulianti Saroso infectious disease hospital on September 14. She is in stable condition and is described above as a "danger point".
The description is consistent with rumors that she is a contact of an eighteen month old girl with initials RH. RH was admitted on September 18 with bird flu symptoms and is in critical condition.
Thus, at this time there appear to be two clusters linked by contact, RD and her nephew, and MG and RH. However, geographically MG and LR are also probably linked to RD raising serious questions about casual transmission of H5N1.
The concerns have led to the National Extraordinary Happening which is cause for concern.