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Casual Human Transmision of H5N1 in Jakarta Raises Phase 5 Flags

Recombinomics Commentary

September 20, 2005

The reason for this, according to Minister of Health Siti Fadilah Supari, is that the number of victims is higher following the case of Iwan Iswara, an auditor at the Supreme Audit Agency (BPK), who died together with his two daughters a month ago.

"At that time, there was only one occurrence, that of Mr Iwan and his daughters. But now, there are two others, that of Rini Dina and Mutiara," said Supari during a meeting at her office in Jakarta on Monday (19/09).

Rina Dina died at Bintaro International Hospital on Saturday (10/09), while Mutiara is still being treated at Suliyanto Saroso hospital.

The above comments highlight the increase in human-to-human transmission, but the number of people developing symptoms is increasing steadily and most transmissions appear to be casual.  These casual transmission are cause for major concern.

The first two suspect cases in the current wave suggest infection linked to close proximilty to a slaughterhouse may have cause the initial cases.  Rini Dina developed symptoms on August 31 and was reported to live 100 meters from a slaughterhouse.  One September 6, a 2 month old baby boy, Livo Rusting died of pneumonia.  He had bird flu symptoms and lived above a slaughterhouse, which may have been the same slaughterhouse 100 meters from Rina Dina's home.

However, Rini Dina was a immigration officer and would have little contact with poultry.  Similarly, the 2 month old would not have had direct contact.  Both have died and Rini Dina tested positive for H5N1.

A neighbor was also reported to have developed symptoms, and this was probably Mutiara Gaytri, a 6 or 7 year-old girl who was initially admitted to Siloam Gleneagles hospital in Tangerang and then transferred to Suliyanto Saroso on September 14.  She was also positive for H5N1 Thus, three neighbors appear to have been infected over a relatively short time frame..

However, H5N1 was transmitted further.  Rini Dina's 8 year-old nephew also tested positive for H5N1 and it is not clear if he is Firdaus, a 9 year-old also at the Saroso hospital.  He may not have been admitted yet, but has begun to show symptoms.

As noted above Mutiara Gaytri also transmitted H5N1.  This transmission is said to be to an 18 month old contact with initials RH, who was admitted September 18 in critical condition.

Also admitted that day was Rosani Ningsih a three year old who is also in critical condition,

Early on the morning of September 19, a two or three year old girl named Windy Lisa was also admitted.  She lived near a chicken farm in the northern section of Jakarta.

Today a five year old girl, Riska Ardian, was transferred to the hospital and placed on a ventilator,  She had initially been diagnosed as having measles.

In addition to the steady stream of children being admitted, there are now at least three workers from the Ragunan Zoo, including a 28 year-old tour guide, a 39 year old food vendor, and a 50 year-old trader, who may be the second food vendor described in media reports.  The zoo employees would not be expected to have close contact with the birds at the zoo, who are asymtomatic but have tested positive fro H5N1.  The zoo workers are developing symptoms at about the same time signaling a major up-trend of patients who have bird flu symptoms but don't have direct contact with birds.

The growing familial and geographic clustering of cases in a relatively small area are cause for concern and suggest the pandemic has moved to phase 5, which is characterized by growing clusters of cases.

The lack of close contact with suspect sources of H5N1 infections raise concerns that the clusters will continue to grow, signaling a significant increase in efficient human transmission.  The transmission is cause for concern is Jakarta is a major metropolitan city with an International Airport.

More testing and sequence data would be useful to see if the virus is novel and is a recombinant.  Testing to see if the H5N1 is the same in the zoo employees and the Tangerang neighbors would be useful, as would the sensitivity to the amantadines.


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