Commentary
Delay and Denial Control of Indonesia H5N1 Clusters
Recombinomics Commentary 04:13
June 7, 2008
The death of the 15-year-old girl described in the 2nd paragraph of the above report would raise the case total to 134 and the number of deaths to 109, if confirmed independently.
It is not clear, however, whether this case is one of the 2 suspected cases described in ProMED-mail on 14 May 2008 (see: Avian influenza, human (47): Indonesia, susp 20080514.1623). In this posting it was reported that: "A 16-year-old girl died 4 days after being admitted to the Persahabatan Hospital in the Indonesian capital on 8 May 2008
with laboratory test later confirming she had the avian flu virus. 10 days before her death, her 15-year-old brother died after a brief treatment at another hospital with symptoms similar to bird flu." The cause of death of the 15-year-old could not be confirmed because no blood sample had been taken. It is possible therefore that the death toll may now be at least 110. - Mod.CP
The above discussion from today’s ProMED commentary on the new Indonesian policy on delaying announcements of H5N1 fatalities is curious. Usually ProMED excludes any suspect H5N1 which are not lab confirmed, even when the unconfirmed case is in a fatal H5N1 confirmed familial cluster. The announcement by Indonesia may have served as an epiphany for ProMED commentator. \
The preceding Indonesia cluster was quite similar. The fatality of the index case was mis-diagnosed as dengue fever and the death was quickly followed by an H5N1 confirmed death in a sibling. That cluster was picked up by wire services and when director general of communicable diseases, Nyoman Kandun, was specifically asked about the cluster, the incorrect dengue fever diagnosis was used to deny the cluster, and this denial was accepted and supported by the same commentator cited above.
The latest comments are a step in the right direction, but the commentary above fails to note that the brother was diagnosed with typhus. Thus, the delay in reporting the case above has already created confusion regarding the diagnosis of the fatal infection in the index case. The commentary also fails to note that the time gap between the index case and the confirmed cases in each cluster supports human to human transmission.
The time gap was also present in the cluster confirmed on the same day as the earlier cluster. That cluster was not picked up by the wire services, but a relative of the confirmed case had died of respiratory disease just prior to the death of the H5N1 confirmed case.
Thus, there are three recent clusters. In each cluster the index cases dies and the cause of death is mis-diagnosed (respiratory disease, dengue fever, and typhus), while the relative then dies of lab confirmed H5N1,
It seems likely that this series of denied clusters may have contributed to the decision to delay H5N1 reporting and reduce transparency. The delay in reporting is in violation of the International Health Regulations, which added H5N1 to the reportable disease list, which requires immediate notification of human H5N1 cases. These regulations were revised in 2005 to increase transparency and give WHO the authority to investigate suspect cases, even without direct participation of host country agencies.
The rapidly deteriorating situation in Indonesia indicates it is time for the WHO to exercise its newly acquired options.
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