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The situation in Bali worsens with the death of a 40-year-old woman from suspected avian influenza within the city limits of the capital of Denpasar itself.  She had no known contact with poultry, although she lived near a cull of some 6,000 birds, following the initial human cases.  A total of nine people have been hospitalized, two testing positive and a third suspected death caused by the virus but no samples taken (!), and a total of four dead out of the nine suspected cases.

A young 17-year-old housemaid succumbs to H5N1 in Tangerang, just west of Jakarta, despite having no direct contact with poultry.  No less than a half-million chickens, however, are suspected of having died of H5N1 in the region surrounding her home/workplace.  Reports begin to trickle out of Indonesia that chicken farmers have been vaccinating their flocks with H5N2 vaccine, making a new class of poultry -- infected but asymptomatic.  And finally, the Indonesian government decides to stockpile prepandemic vaccine "in people, not in warehouses," evoking the ghosts of the 1976 Swine Flu decision by the Ford Administration here in the United States and yet another poor example of Indonesia thumbing its nose yet again at the WHO.

All this adds up to a horribly mismanaged situation in the nation of 18,000 islands.  And the United States and the UN must take whatever diplomatic steps are necessary to restore confidence (if possible) that the surveillance and eradication programs are meeting global standards. 

Too much is on the line.  It is painfully clear that Health Minister Siti Fadilah Supari is either ridiculously misinformed, or is blindly doing the bidding of those who would profit personally and relentlessly from the Baxter deal.  Newspaper and Internet reports begin to indicate that the Indonesian people themselves might be tiring of her tactics, holding the rest of the world hostage in a viral extortion deal of someone's making -- possibly hers, but I strongly suspect other hands are at work.

If these outbreaks in poultry continue, and if human deaths continue -- especially on the previous paradise known as Bali -- there will almost certainly be growing pressure on the government, from within and from the political opposition parties, and among the general population as a whole, that the nation's leaders have failed to contain the bird flu problem.  We have seen one nation's government overthrown already (Thailand) at least patrially because of the bird flu problem.  Thai leaders' failure to tell the truth about H5N1 outbreaks helped bring down the elected government (the military coup followed a severe outbreak of H5N1, and opposition leaders were constantly denouncing the government's inability to tell the truth to the Thai people.  For a history of Thailand's government lies on H5N1, read Mike Davis' The Monster at our Door).  So the precedent is set.

No one wants to see instability in the political makeup of Indonesia.  Still, the US and the UN have an obligation to make some sense out of what is happening down there.  It is time to bring in the diplomats and start playing hardball with this recalcitrant nation and stop pussy-footing with them.  And since upwards of 20% of all stray cats in Indonesia show antibodies to H5N1, maybe pussy-footing is the right choice of words in more ways than one.

So many other bloggers have covered this already, I am late to the dance.  Here are some links to the story of the latest Bali bird flu death:

http://afludiary.blogspot.com/2007/08/another-bird-flu-suspect-dies-in-bali.html

http://crofsblogs.typepad.com/h5n1/2007/08/second-bali-dea.html

The 28-year-old woman was from Kediri, Tabanan regency, around 20 kilometers west of the capital city of Denpasar,  I have made the necessary adjustments on the Bali map. 

Just when things start getting interesting in Indonesia again, Egypt clamors for attention.  This time, a duck along the Nile Delta has tested positive for an H7 avian flu.

H7 avian influenza is a milder, low-pathogenic strain.  But, as we have seen just a few months ago in Wales, and as we saw in the Netherlands and Germany in 2003, H7 is also ridiculously easy for humans to catch from birds -- and also is apparently quite easy to pass from human to human, or H2H in the shorthand of fludom.  

I would add that the two people from Liverpool who caught February's H7N2 in Wales and thought they were going to die, or the relatives of the vet who died in the Netherlands in 2003 from H7N7, would dispute that "mild low path" statement.

The location of this H7-positive duck is in Ash Sharqiyah (Sharkia), located in the North Nile Delta near the Mediterranean Sea.  Wait, you say, that sounds familiar.  Exactly.  Just last month, I talked about the emergence of a new human case of H5N1 infection, that of a 25-year old woman in Damietta.  The post is located at http://www.scottmcpherson.net/journal/2007/7/22/new-bird-flu-case-in-egypt.html . Damietta is north of Sharqiyah, but the two governates are uncomfortably close together. 

Regrettably, that region of the Nile has also been the location of earlier suspected outbreaks of H5N1 in poultry.  And as we have discussed before, the further north you travel up the Nile, the higher the human mortality from H5N1.  The Egyptian government is blaming migratory wildfowl -- ducks, to be specific -- for bringing this new strain via Europe.  Which is logical, considering the well-documented outbreaks of H7N2, H7N3 and H7N7 that have occurred in Europe since 2003.

Now let's tie all this together.  One of the things keeping influenza researchers like Dr. Henry Niman awake at night is the prospect of an H7 flu recombining or reassorting with H5N1 and producing a virus that is much more easily transmissible from human to human, while maintaining the more nasty characteristics of the H5N1 virus.  So if H7 is pretty easy to transmit H2H (by all appearances it is), and if H7 and H5N1 could hypothetically evolve, say, in the lungs of a pig or a child or a young adult, then it is reasonable to be concerned.  The co-presence of H7 and H5N1 in the same region that has been slammed with avian influenza infections is a grave cause for concern.

Here is the link to Dr. Niman's commentary on just this situation:

http://www.recombinomics.com/News/08210701/H7_Nile_Delta.html

Make no mistake:  Australia is reeling under the weight of one of the worst seasonal flu epidemics in the past twenty years.  And this provides an excellent glimpse at what a pandemic -- even a mild, 1968-ish pandemic -- can and will do to a nation in the globalized, 21st century.

First, let us get up to date.  The seasonal infections are both H3N2 and H1N1.  The WHO vaccine targets for the 2006-07 Northern Hemisphere and the 2007 Southern Hemisphere flu season were identical.  It may be too early to know if these targets were on the money, or were off.  It is not known how many Australians took their flu shots this year.  If fewer Australians took their shots, it would help explain why the virus has hit the island nation so hard this year.  Or perhaps new substrains emerged Down Under, and drifted beyond the ability of the seasonal vaccine to intercept and destroy them.

But look at the parade of daily news articles streaming from the beleaguered nation.  First came the revelation that adults were dying of the seasonal flu.  Australian deaths include three otherwise-healthy adults - a 37-year-old Queensland man, a 48-year-old woman from South Australia and a 33-year-old Queensland mother-of-two.  

"These figures are growing proof that we're having a heavier season this year than we have in previous years," said Professor Anne Kelso, director of the Melbourne-based World Health Organisation Influenza Centre.

http://news.ninemsn.com.au/article.aspx?id=97550

Flu cases are running three times the five-year average, so the morbidity spike is quite pronounced.  It is an epidemic that is much more serious than normal -- so much so that none other than Professor Graeme Laver has called for the dispensing of Tamiflu, without prescription, directly from chemists (pharmacists).  In case you did not know, Professor Laver is one of the bona-fide Influenza Rock Stars, and he is right up there with his friend and peer Dr. Robert Webster.  Laver's research led to the creation of Tamiflu, although how they ever settled on Chinese Star Anise as the extract is beyond me. 

Anyway, Laver contends that Tamiflu is safe enough to be sold over-the-counter.  I am not sure the Japanese would agree with that statement, based on the research showing Japanese youths who took the antiviral attempting and occasionally committing suicide and showing other bizarre behaviors.  This was a major reason for Roche introducing smaller, 30 mg and 40mg Tamiflu capsules, made especially for younger children (the adult dose remains at 75mg).  The smaller doses are now EU and FDA-approved.

This Tamiflu over-the-counter release would be fine, well and dandy, if Australia had enough Tamiflu to distribute.  But the Aussies run their economy the same way the rest of the world does, via the Just-in-Time supply chain, which we all know is as doomed as doomed can be in a pandemic.  Worried and panic-stricken moms across the nation are driving around, desperately trying to find Tamiflu to buy for their flu-stricken children.  So last week the Australian government, under considerable pressure from those moms, agreed to release part of their pandemic stockpile for sale -- but still via prescription. An article, posted by fellow flu blogger and all-round nice person SophiaZoe, can be found at http://www.goldcoast.com.au/article/2007/08/10/1471_gold-coast-news.html and here is a short excerpt: