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The bird flu news is coming strong out of Vietnam and Indonesia again this week.  In Tangerang, Indonesia, (search my blogs for previous references to Tangerang) a familial cluster has manifested itself.  A 38 year-old mother came down with H5N1 on or about January 23, and, wouldn't you know it, but about a week later her 15 year-old daughter exhibited bird flu symptoms.  Both have tested positive for H5N1 and are in hospital. the human-to-human (H2H) potential is huge, because of the staggered onset of symptoms.  I would say, based on that staggering of onset dates, that H2H is the most likely cause here, although not yet set in concrete.

Now, in northern Vietnam, not one, but two H5N1 human cases have flared up in less than a week.  One 40 year-old male patient has already died, and the other, a 27 year-old man, is on a ventilator and not doing well at all.

The Indonesian cases are almost certainly of their peculiar clade 2.1, while the Vietnamese cases are speculated to be the newer Fujian clade, designated 2.3.4 by the WHO.  As you recall, Fujian H5N1 was identified in 2006 by a research team that included Doctors Yi Guan of the University of Hong Kong and Robert Webster of St. Jude's.  You don't get much better than that!  From the CIDRAP news release of November 3, 2006, titled "Study says new H5N1 strain pervades southern China":

The authors contend that their findings show that the spread of the Fujian-like strain "has initiated a new transmission wave in Southeast Asia," comparable with the first wave in the region in early 2004 and the spread of H5N1 to Europe and Africa following China's Qinghai Lake outbreak in the spring of 2005. They say it is to blame for recent poultry outbreaks in Laos, Malaysia, and Thailand and for recent human cases in Thailand. 

http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/nov0306China.html

Sure enough, look at the human cases since 2005.  Since the discovery of Fujian H5N1, human cases have been reported in Southeast Asia.  The statistics point to a higher mortality rate than existed before 2006, which makes it a very strong competitor in terms of mortality with the Indonesian substrain. It is becoming apparent that Fujian H5N1 has acquired the same kliller instinct as its Indonesian kin. 

If we don't get some really good data from Indonesia soon, I am deeply concerned where this whole Tangerang thing is going.  Exactly where we stand in this Mexican standoff with the Indonesian government, I am not sure.  Let's hope we have a breakthrough on the diplomatic front soon.  The longer the world is deprived of the Tangerang samples, whenever and wherever source they come from, the deeper the hole we make for ourselves.

It is equally important that we get good sequencing data on Fujian H5N1's evolution.  While Qinghai spreads like proverbial wildfire across south Asia, I am absolutely amazed there have been no cases of mass infections of H5N1 in humans.  So maybe Qinghai is not the eventual pandemic substrain.  A killer of economies and a bane to the existence of poultry worldwide to be sure, but maybe not the substrain that will do us in.  Maybe that substrain still smoulders in Tangerang, Indonesia, or closer to Jakarta, or maybe in some Laotian jungle.