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H5N1 Cluster Raises Surveillance Concerns In Indonesia

Recombinomics Commentary
October 3, 2007

Within five months, a family from Rawa Buaya subdistrict in West Jakarta lost two children to what was diagnosed as typhoid fever by doctors at the Sumber Waras Hospital.

AR, 22, died last Friday after suffering from high fever, headaches and respiratory problems.

His 19-year-old sister died after suffering similar symptoms in April.

However, on Monday the Health Ministry confirmed that the cause of both deaths was avian influenza.

The above comments once again raise concerns about H5N1 detection in patients in Indonesia and elsewhere.  In the 1918 pandemic, the most common misdiagnosis were typhoid fever, dengue fever, and cholera.  In the current H5N1 outbreak, the misdiagnosis of H5N1 as typhoid and dengue fever is common.

In Thailand, the most cited example of human-to-human transmission in 2005 was initially diagnosed as dengue fever.  In Indonesia, one of the larger clusters, was on south Sumatra and was initially diagnosed as typhoid fever.  In the south Sumatra cluster, all three family members survived.  Survival of H5N1 confirmed cases in Indonesia is rare, and many such cases were identified because they were contacts of confirmed cases.  The clustering also led to H5N1 testing in misdiagnosed patients.

The high case fatality rate in Indonesia may be a function of testing procedures.  Most testing is done on advanced cases which are transferred to infectious disease hospitals.  Patients who recover at local hospitals are not tested.  Thus the case fatality rate be lower, but the number of H5N1 infections may be markedly greater than the confirmed cases.

The presence of H5N1 in areas that have large numbers of dengue and typhoid fever remains a cause for concern.

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