Commentary
Indonesia H5N1 Cluster Reporting Failures Increase Concerns
Recombinomics Commentary 14:37
June 6, 2008
Health Minister Siti Fadillah Supari, who has clashed with the international community and United States over her handling of health issues, on Thursday said her ministry had changed its policy and would only report cases every six months.
She did not say whether that reporting policy also included the World Health Organisation (WHO). But a health ministry official said on Friday that the ministry had not decided yet whether it would report to the WHO every one, two, or three months.
"We are obliged to report to WHO, we are also obliged to report it to the public," said Nyoman Kandun, director-general of communicable diseases at the health ministry, adding that the new policy was meant as a better way to "package" the information.
The above comments are out of compliance with the 2005 revision of the International Health Regulations, which specifically cite “human influenza caused by a new subtype” as a notifiable disease which is to be reported to WHO within 48 hours.
The comments on the new Indonesian policy, have been raised in response to an H5N1 fatality that was not reported for over a month. The case received considerable local media attention, because the brother of the confirmed case had died days early with identical symptoms, including cyanosis in extremities. There was little doubt that these fatalities represented an H5N1 cluster, which followed two other clusters involving fatalities which included H5N1 lab confirmed cases.
In each of these clusters, the index case was mis-diagnosed and the mis-diagnosis was obvious because of the H5N1 lab confirmation in a fatally infected relative. In one cluster the index case was said to have died from respiratory disease. This cluster was only covered by the local media.
However, the second cluster was picked up by wire services, and Nyoman Kandum was specifically asked about the death of the index case and he said the brother died from dengue fever. This comment raised significant doubt about H5N1 transparency in Indonesia linked to significant under-reporting of cases and clusters.
The most recent cluster has still not been listed by WHO as a lab confirmed case, although media reports indicate H5N1 has been confirmed by two or more independent labs. The delay was said to be due to a consideration of the new reporting policy. In this latest cluster, the brother’s death was mis-diagnosed as typhus.
These mis-diagnosis are obvious, and are usually corrected when H5N1 is confirmed a relative who has disease onset dates within days of the earlier case. In all three of these clusters, the time differential in disease onset dates strongly suggesting that these clusters represented human to human transmission, yet none of teh clusters have been acknowledged or reported to WHO..
The decision to revise the reporting frequency, in clear violation of International Health Regulations, is cause for concern, as is the WHO’s failure to investigate the index cases in each cluster. Although H5N1 clusters are not new in general or to Indonesia in particular, the failure to investigate these clusters has created conditions that allow for less transparency.
Although H5N1 infections have recently been reported at record levels in India, Bangladesh, and South Korea, many media reports assume that the decline in confirmed human cases reflects a reduced risk and a lower incidence of human H5N1 infections. However, the limited number of human cases in the above outbreaks, as well as the outbreak in Pakistan, is almost certainly due to detection / confirmation / reporting failures.
These failures, and the WHO’s acceptance of this lack of transparency, encourages countries to conceal cases and / or announce new reporting policies in clear violation of IHR.
The WHO has an obligation to enforce these regulations, which it has avoided for some time, and reporting failures have been most obvious in recent months.
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