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Fatal Suspect H5N1 Cluster in South Sulawesi
Recombinomics Commentary
October 20, 2006

the Official of the Maros Health of the Service took the sample of blood against five citizens in the Bontopaddingin Village, the Bontotallasa Village, the Subdistrict Toss Up, on Wednesday October 18 yesterday.The taking of the sample of this blood, related the death a baby, Fajrin, 2 months that was expected suspect avian influenza (AI) or bird flu.

They who were taken the sample of his blood respectively the two parents Fajrin, the Dervish, 22 years with his wife, dahlias, 29 years.Three other citizens were still being the grandfather and the close Fajrin family respectively Kurdin, 60 years, Hj Indeed, 55 years, and Harbiah, 35 years.A Service staff the Maros Health, Muhammad Said, SKM M. Cash that led the taking of the sample of this blood in the location, mentioned, from the five citizens, two including being expected suspect bird flu.

The above translation describes a suspect fatal H5N1 bird flu case in South Sulawesi.  In addition, at least two family members are hospitalized and several contacts are being tested.  The H5N1 situation in South Sulawesi remains unclear.

Last month a fatal confirmed case from Mekassar was announced.  However, the patient had died in June.  The WHO update indicated the delay in reporting the confirmation was because it was collected during routine testing.  However, the WHO update failed to mention the deaths of two family members who also had bird flu symptoms.  Thus, the failure to report, couple with the misleading characterization by WHO is cause for concern.

Between the earlier fatal cluster and the current suspected fatal cluster, a large number of suspect cases have been hospitalized in South Sulawesi.  Although these cases have tested negative, patients have been treated with Tamiflu which may lower the level of circulating H5N1 to a level that is below detection.  False negatives are common in H5N1 cases and frequently multiple tests are required to detect H5N1.  A recent confirmed H5N1 fatality in Thailand was tested nine times over several weeks, yet H5N1 was only detected at autopsy.

The frequency of H5N1 infections in Indonesian remains unclear.  The H5N1 in patients does not match the H5N1 in poultry.  Since a link to dead or dying poultry is usually required fro H5N1 testing, the level of H5N1 infections in patients with bird flu symptoms, but without a bird link is largely unknown.

If these patients have been infected with H5N1, they will have antibodies that can be detected 3-4 weeks after disease onset.  It remains unclear how many of any surviving patients with bird flu symptoms are tested for convalescent H5N1 antibodies.

Similarly, sequence data from H5N1 positive cats has not been released.  The only cat H5N1 sequence released to date does match the human H5N1 sequences, which provides additional evidence for a mammalian reservoir.  Similarly, analysis of recently released H5N1 sequences in China show that recombination is frequent, and regions of identity are found in Indonesian patients, providing evidence for the introduction of new polymorphisms in Indonesia via migratory birds. H5N1 sequences from wild birds in Indonesia are also lacking.

The latest suspect cluster in Indonesia again highlights the need for expanded  surveillance and more timely reporting. 

Recent media reports indicate that there will be testing of waterfowl in the Trisik area, Yogyakarta, and the Eretan Coast, Indramayu.  Thus far the only reported bird H5N1 from Java with the novel cleave site was from Indramayu.  Although it did not match the majority of human cases, it was close to a small subset of patients infected at the end of 2005.  The only other bird isolates with the novel cleavage site were from central Sumatra.

 Although the novel cleavage site has not been detected outside of Indonesia, many polymorphism from patients in Indonesia have been detected in H5N1 in China, strongly implicating these isolates in the evolution of H5N1 worldwide, including several polymorphism that were widely detected in Indonesian patients.  Moreover, the origins of these H5N1 sequences in China could be found in low path isolates in Hong Kong in the late 1970’s indicating low path flu sequences are also closely involved in the evolution of H5N1, which is largely driven by recombination, which was readily detected in the H5N1 from poultry, waterfowl, and swine in China.

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