18 August 2006
H5N1 outbreak investigation begins in remote village of West Java, Indonesia
The WHO posted on their website (www.who.int) August 17th that the Indonesian Ministry of Health reported the death of a 9 year-old girl from a remote village in West Java province (Garut District) due to H5N1 avian influenza virus. Indonesia and the WHO have launched an investigation into the three hamlets within the one village where the 9 year-old child died because of an additional laboratory-confirmed H5N1 infection in a 17 year-old young man in a second hamlet in this village, and the death of his 20 year-old male cousin (neighbor) of a respiratory disease “strongly suspected” to be H5N, but for whom no samples were obtained laboratory testing.
Of note, the WHO reports that the 17 year-old and 20 year-old young men both developed symptoms on 26 July and this “makes human-to-human transmission between the two highly improbable”. The two cousins are assumed to have “acquired their infection from a shared environmental source”, according to yesterday’s WHO situation update 27. Their remote village in West Java was reported to have recent die-offs of poultry and all three of the patients “documented exposure to diseased chickens”. The 9 year-old girl developed symptoms on August 1st, was hospitalized nearly two weeks later (August 14th), and died the next day.
Rumors of other patients with respiratory disease in the three hamlets of this village during this time frame since late July are being investigated. In parallel, animal health experts are investigating the poultry deaths in this village.
As with the single family-related cluster of H5N1 infections in north Sumatra, Indonesia, in May 2006 one can anticipate further information in the days and weeks ahead. Such information will likely include the results of human epidemiological studies to assess how the infections occurred, and analyses to determine the genetic sequences of the H5N1 viruses from both humans and poultry to assess any evidence of either recombination with human influenza viruses or significant mutations in the H5N1 virus.
Indonesia’s declaration within the past month that they will share such H5N1 viral sequences with the global community is a welcome event in this regard. Indonesia has now reported 58 laboratory-confirmed patients with H5N1 virus infection since the first Indonesian patient was diagnosed in 2005. Of these 58 persons, 45 have died (78%). Indonesia has recently surpassed Vietnam (42 deaths) with the highest number of laboratory-confirmed deaths due to H5N1 virus infection. According to the H5N1 table of confirmed cases on the WHO website, Vietnam has reported zero deaths due to H5N1 virus infection in 2006, while Indonesia has reported 34 deaths this year.
Most importantly, as of today there is NO indication that any evidence warrants consideration of changing the WHO pandemic alert from the current Phase 3 to Phase 4 (i.e., small clusters of human-to-human transmission), or trigger a WHO-partnered rapid response and containment protocol.
Readers interested in considering what would be involved at some future time should Phase 4 develop in any nation(s) in the world should review the latest WHO version (May 30) of this protocol at: http://www.who.int/csr/disease/avian_influenza/guidelines/draftprotocol/en/index.html
Daniel R. Lucey, MD, MPH
Director, Center for Biologic Counterterrorism and Emerging Diseases
EROne Institutes, Washington Hospital Center Emergency Department
Adjunct Professor of Microbiology and Immunology
Georgetown University Medical Center, Washington, DC
Website of posting: www.BePast.org e-mail:Daniel.R.Lucey@Medstar.net