The exception to the rule
Scott McPherson
in influenza and infectious diseases
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5 Comments
Indonesian child diagnosed with H5N1 goes home to play
Tangerang's Sholeh Alfaruq has been taken home by his parents. Ordinarily, that would seem to be extraordinary news, a real cause for celebration. And any child in Indonesia who recovers from H5N1 is reason to celebrate, considering the 80%-plus death rate from H5N1 there.
But Sholeh is an exception to a rule; an anomoly that needs to be studied carefully. For Sholeh Alfaruq showed only mild H5N1 symptoms; played with neighborhood children even while undergoing treatment; and has gone home against the wishes of his doctors and the Health Ministry. My original blog on him is at: http://www.scottmcpherson.net/journal/another-h5n1-infected-toddler-in-tangerang.html
Sholeh was a neighbor and presumed playmate of Dewi Aprilliani, the four-year old H5N1-infected girl who died October 22, and her death was reported to the world the following day. Her death marked the second death in as many weeks in Tangerang, which is located on the outskirts of the capital of Jakarta. My blog on that death can be found at: http://www.scottmcpherson.net/journal/2007/10/24/new-h5n1-death-in-tangerang-indonesia.html
From the Borneo News via wire service AFP:
Indonesia's bird flu boy defies hospital orders, returns home | |
| JAKARTA (AFP) - The parents of a three-year-old Indonesian boy infected with bird flu have defied hospital orders that he stay in isolation and taken him home, a hospital official said Wednesday. The boy from Tangerang, a satellite city west of the capital Jakarta, stayed in hospital for just half a day last Saturday, said Sardikin Giriputro, deputy director of Sulianti Saroso hospital. "We had no choice but to let the boy leave the hospital as his parents insisted on taking their child home," Giriputro told AFP. He said a patient should remain in isolation until a test showed the infection was over. Doctors wanted him to remain in isolation to ensure there would be no possibility of human-to-human infection, he said. Giriputro added that the boy was under home observation by medics from a health centre in Tangerang and Wednesday's report said that his condition was improving. The mother of the boy, Muslimah, told the online Detikcom news agency however that he was in good health and medics only visited initially. "At the beginning, some doctors came here, but they haven't come anymore... My son has recovered, he's now in good health. He isn't taking medicine anymore," she was quoted as saying. |
http://www.brunei-online.com/bb/thu/nov1w5.htm
So this child has apparently fully recovered from H5N1 and has returned to his neighborhood. Tangerang has experienced multiple H5N1 fatalities in the past year. As alert multiflusite poster Theresa42 points out, this raises many, many fundamental questions. The following is taken from her Flutrackers.com post, and she hat-tips fellow poster BlueJay. This is from television station Liputan6.com. Machine translation from the native Malay.
Flu parents Deny Diagnosis Be Positif towards Anak
01/11/2007
Liputan6.com, Tangerang: Although being diagnosed positive terjangkit the bird flu virus, Sholeh that was the Tangerang resident, Banten, was still undergoing the activity as usual. He playing was proper for the healthy child. The child was three years old this could be treated in the hospital, but was returned by his parents that regarded his illness of only common fevers.
In fact in the area of his residence, the Suka Asih Village, of Kecamatan Pasarkemis, Tangerang, some time set had one resident who was killed resulting from bird flu [read: Menkes Pesimistis Indonesia Bebas Flu Burung]. After the incident, the official of the local Health of the Service checked the example of villagers's blood. The official afterwards stated Sholeh positive was affected by the same illness. Sholeh could be then carried to the Hospital of Penyakit Infeksi Professor Doktor Sulianti Saroso, Sunter, Jakarta Utara.
However, parents Sholeh forced Putra him to be returned because of being convinced the healthy child. Moreover, the good intention to the official of the Health of the Service was then refused by parents Sholeh, including the medicine that was given by them. As for till October 29 2007, the Kesehatan Service side recorded had 14 people died in the Banten Province resulting from bird flu.
http://www.liputan6.com/sosbud/?id=150093
OK, here's the bottom line: We have a situation in this neighborhood in Tangerang where a four-year old girl died from H5N1, and a week earlier a twelve-year old boy also died. According to the television station, fourteen people have died from bird flu in the province since 2005.
Immediately following the deaths, the authorites swarmed over the village, taking blood samples of the neighbors and especially their children. That is apparently how young Sholeh was found to be H5N1-positive. He was apparently showing flu-like symptoms as early as October 22, although that date is not set in granite and may also have been October 26th. After just a half-day in hospital, however, Sholeh is released at the insistence of his parents, and is apparently being monitored at home by physicians, although competing news accounts also allege the parents have not seen medics in days.
This sudden existence of a mild case of H5N1 is not unique to Indonesia. In Egypt, the further south you are along the Nile Delta, the more likely the human cases of H5N1 are mild and survivable. The further north along the Delta, the more likely you are to die from H5N1.
This emergence of almost asymptomatic H5N1 among children is very disconcerting. The good news is that this may actually indicate the case fatality rate from H5N1 is significantly less than the 60% worldwide, or the 80% found in Indonesia. On the other hand, it could mean the virus is far more prevalent and widespread than first thought, and we are much further along the path to a reassortant or even worse, a recombined pandemic flu virus than anyone originally thought.
How can the world health community determine this? Only by developing a quick, easy test for H5N1 antibodies that is as prevalent and easy to obtain results from as the swab test people get at the doctors' office.
Reader Comments (5)
I'm confused. Actually I just don't understand...Do you mean that a mild strain could "reassort" meaning get more virulent? And a "recombination" would be a couple different strains combined? Could you please explain it to me so I can comprehend this? Thanks in advance.
A virus that no one seems to think is particularly harsh could still contain the ability to become lethal. Look at the 1918 virus for proof. The first wave was relatively mild, with morbidity and mortality no worse than seasonal flu from 1915-1917. Then, the second wave kicked in. Somehow, the virus aquired a lethality not seen in the previous wave.
I think it is entirely possible that a human H5N1 and, say, a swine H5N1 could recombine or reassort to produce a very lethal human virus. Or it could reassort with another human flu virus to create a reassortant with increased lethality.
The mild strain could recombine with itself and produce something horrible, or it could reassort with other strains.
This could also be a false positive...there are many opportunities for error in the collection and analysis of blood samples.
However, in comparison, the odds for false negatives are more likely due to the additional mutability of the virus, constantly drifting away from test reagents.
Courtesy of K from Mi. http://www.kapanlagi.com/h/0000197480.html
If the poultry were asymptomatic, it would still show in their blood. Apparently all poultry around 3 cases showed negative.
ANd considering people are still dying in tangerang, we all agree there should be a huge push to get more equipment and more boots -- preferably accompanied by reporters from outside of Indonesia -- into the district.