Commentary
WHO Commission By Omission On H5N1 H2H In Indonesia
Recombinomics Commentary 18:06
June 20, 2008
Heymann told Reuters the WHO encourages all governments to provide information freely to their populations, but it is their decision.
Today's WHO statement, citing information from the Indonesian health ministry, said the 16-year-old girl was from South Jakarta and fell ill on May 7; she was hospitalized May 12 and died 2 days later. There was evidence that she had been exposed to sick and dead poultry, the agency said.
A WHO official who requested anonymity told CIDRAP News this week that the agency had been aware of recent H5N1 cases in Indonesia despite the delay in receiving official notification.
Speaking before the latest case confirmations, the official said, "The fact that you don't yet have official notification of any cases doesn't mean there isn't unofficial awareness." He said the two recent cases didn't change WHO experts' assessment of the risk posed by the virus.
If the cases had signaled more of a threat, the information would have been handled differently, he suggested. "If we were dealing with something much more serious, I think there would be a very, very different approach by all involved in getting the information. If you had a cluster of something behaving in an unusual fashion, the pressure to share it would be very high."
The above official and unofficial comments from WHO are curious. Officially, WHO is saying that information on human H5N1 cases in Indonesia should be shared, and WHO routinely publishes situation updates shortly after confirmation of human H5N1 cases. However, unofficially, WHO had knowledge of the above May case long before receiving notification from Indonesia, which was withheld in violation of IHR regulations which require notification of human cases within 24 hours.
The withholding of the information from the situation update is somewhat understandable because the confirmation of the case was not official. However, when WHO did publish the update, the exposure to sick and dead poultry was mentioned, but the exposure to the brother of the confirmed case was not. He had died 10 days prior to the death of the confirmed case, strongly suggesting that he infected the confirmed case. Although the brother was misdiagnosed with typhus, neither the typhus diagnosis nor his death was included in the update. Similarly, the hospitalization of another brother after the death of the confirmed case was also not mentioned. The second brother tested negative for H5N1, but false negatives are common in Indonesia, especially for samples collected after the start of Tamiflu treatment. Such treatment is common for contacts of confirmed cases.
Thus, this cluster had at least three family members, and the death of the first brother strongly suggests that he was H5N1 infected and infected his sister, who may have then infected her other brother, based on disease onset dates. WHO consultants are well aware of the frequent misdiagnosis of H5N1 cases in Indonesia. Such misdiagnosis in patients who were subsequently H5N1 confirmed were tabulated in a New England Journal publication from the beginning of this year.
On condition of anonymity, the WHO official above noted that this cluster was not behaving in an unusual manner. This comment is supported by additional clusters in March, which also included an H5N1 confirmed case linked to a fatally infected family member who was diagnosed as having lung inflammation or dengue fever. However, although such clusters are common in Indonesia, these clusters do not appear in WHO situation updates, or in WHO comments on new cases. As noted above, the WHO update implies the confirmed May case was from poultry exposures, instead of the dead brother who had a disease onset date consistent with human to human (H2H) transmission to his sister.
Although the H2H transmissions in Indonesia are not unusual, most of the general public who accept official denials or WHO omissions at face value would be surprised at the level. Moreover, the reliance on tests of samples collected after Tamiflu treatment for diagnosis leads to significant under-reporting of cases and clusters.
Thus, although WHO officially supports transparency on human H5N1 infections, its situation updates are glaring examples of commission by omission of significant data supporting frequent H2H transmissions in Indonesia.
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