Update: Indonesia cluster

AVIAN INFLUENZA, HUMAN (139): INDONESIA
*******************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Sun 3 Sep 2006
From: Mary Marshall <tropical.forestry@btinternet.com>
Source: The Mercury News online, Sun 3 Sep 2006 [edited]
<http://www.mercurynews.com/mld/mercurynews/news/world/15425359.htm>


Indonesia: Analysis of the North Sumatran Cluster
-----------------------------------------------
Dowes Ginting, the most wanted man on Sumatra island, lay dying. He
had abandoned the hospital where he had seen his relatives succumb
one after another, and he had fled deep into the mountains, trying to
outrun the black magic he feared had marked him next. For 4 nights,
witnesses recalled, a medicine man hovered over him in a small
clapboard home, resisting the evil spell.

Ginting, a wiry 32-year-old, had watched disease burn through his
family over the previous 2 weeks, killing 6 and sickening 2 others,
including himself. International health experts grew increasingly
concerned when laboratory tests confirmed they were sickened by bird
flu, the largest cluster of the disease ever recorded. But Dowes
feared medical treatment more than he did the avian influenza. And so
he ran, potentially exposing villagers across the province to the
highly lethal virus.

In the end, the outbreak in May 2006 did not presage the start of a
worldwide epidemic. But the enormous difficulties that Indonesian and
international disease specialists confronted in investigating the
outbreak and protecting against its spread raised fundamental
questions about whether bird flu could be contained if it mutated
into a form more easily spread among people. "If this were a strain
with sustainable transmission from human to human, I can't imagine
how many people would have died, how many lives would have been
lost," said Surya Dharma, chief of communicable disease control in
North Sumatra province.

Officials from the World Health Organization (WHO), drawing on
sophisticated computer modeling of a theoretical bird flu outbreak in
Southeast Asia, have suggested that a pandemic could be thwarted
through a rapid containment effort in the affected area, including
the right mix of drugs, quarantines and other social controls. To
succeed, the anti-viral drug Tamiflu would have to be distributed to
90 percent of the targeted population, roughly defined as those
within at least a 3-mile radius of each case. The drug would have to
be administered within 21 days from the "timely detection" of the
initial case of an epidemic strain. Residents would have to stay
home, limit contact with others and take the medicine as prescribed.
In the case of the North Sumatra cluster, almost none of this
happened, according to extensive interviews with health officers,
family members and villagers. The underlying problem was that most
family members and villagers were convinced that magic, not flu, was
to blame. "How can you ever get people to cooperate if they don't
even believe you," Dharma said.

Health investigators have concluded that the 8-person cluster in
Sumatra began with Ginting's older sister, who fell ill in late April
[2006]. They suspect she was infected with bird flu from live
chickens sold in a market where she peddled oranges, limes and chili
peppers or from contaminated poultry droppings in manure used in her
garden. She died and was buried before any samples were taken to
confirm bird flu. Several days after she became sick, the extended
family had gathered in the village of Kubu Sembilang for a feast of
roast pig and chicken curry to celebrate the annual harvest festival.
That night, many of the relatives slept in the same small room with
the sister, who had developed a serious cough. By the time she died,
a sister, a brother, 2 sons, a niece and a nephew had become ill. Flu
specialists said the final victim, her brother Dowes Ginting, in turn
probably caught the virus from his infected son. Health experts have
concluded this was the 1st time the bird flu virus had been passed
from one person to another and then on to a 3rd person.

"None of us thought it was bird flu. We thought it was black magic,"
said Anestia Tarigan, the wife of the youngest Ginting brother,
Jones, the only victim to survive [and not a blood-relative -
Mod.CP]. "Everyone in the family was getting sick and no one else
was. Someone had put a spell on our family. Black magic is very
common in our place."

Indonesian and WHO investigators discovered that many residents in
Kubu Sembilang were unwilling to share information or give blood
samples that could reveal how widely the virus was circulating. Many
villagers believed that claims of bird flu were a lie. Some even
threatened the investigators. When a team of officers 1st arrived
from the provincial health department, they were warned by their
local counterparts that it was too dangerous to enter the village.
Investigators were able to take samples from only 2 people in the
village, including the local midwife, said Diana Ginting, chief of
the district health department, who shares a common surname in the
region. Indonesian health officials working with an international
team returned day after day to the village and made progress. They
recruited 20 local volunteers to monitor fellow residents for fever
and set up a temporary health post on the soccer field offering free
medical care. The investigators methodically pieced together the
chronology of the outbreak. They traced those who had contact with
the victims and provided them with Tamiflu. But many of those closest
to the Gintings refused to take it. As a medicine man treated Dowes
Ginting, Indonesian and international health investigators finally
tracked him down and urged his family to take him to a hospital. They
demurred: He needed 2 more days of traditional treatment, they said.
That night, he took a turn for the worse and died.

[Byline: Alan Sipress, Washington Post]

--
ProMED-mail
<promed@promedmail.org>

[This article provides a useful resume of the investigation of the
cluster of human cases of H5N1 avian influenza virus infection which
involved 8 members of an extended family in the village of Kubu
Sembilang in the province of North Sumatra. For the 1st time, there
was clear evidence of passage of virus from one person to another and
onward transmission to a 3rd member of an extended family. It should
be emphasized, however, that no other comparable cluster of cases has
been identified in Indonesia or elsewhere. There has been no evidence
to date that the H5N1 avian virus is evolving to a form more easily
transmitted from human to human. Similarity of the genetic
constitution of close relatives still seems to be the determining
factor in susceptibility to infection. - Mod.CP]