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It is dang difficult trying to understand what is going on in Indonesia these days.  That is one reason why I am also adjusting to the H5N1 "New Normal" that I blogged about a few weeks ago.  Reports of "hot high"  -- machine translation for high fever -- abound in the Indonesian press.

Most of these accounts wind up testing negative, or so we are told.  Many of us are dubious whenever we hear about negative tests.  Our skepticism was reinforced via yesterday's WHO report on the Pakistani family cluster of last October and November.  Curious that it took so long to confirm what we already suspected.   

The latest WHO report from Indonesia speaks of three confirmed human H5N1 infections.  Two are from West Java; one is from West Sumatra.  All are young.  Two are dead.

What is beginning to percolate up from the local press, captured and analyzed by our worldwide team of flubie lay translators and geographers (you know who you are), is that two of the latest H5N1 cases are related to family members who also complained of "flu-like" symptoms at the same timeframe to suggest human-to-human -- or H2H -- transmission.  First, the WHO official update.

Avian influenza – situation in Indonesia – update 41

2 April 2008

The Ministry of Health of Indonesia has announced three new cases of human H5N1 avian influenza infection. The cases are not linked epidemiologically. The first is a 15-year-old male student from Subang District, West Java Province who developed symptoms on 19 March, was hospitalized on 22 March and died on 26 March .

The second case is an 11-year-old female student from Bekasi City, West Java Province who developed symptoms on 19 March, was hospitalized on 23 March and died on 28 March.

The third case is a 21-month-old female from Bukit Tinggi, West Sumatra Province who developed symptoms on 17 March, and was hospitalized on 22 March. She is presently recovering in hospital.

The source of infection for all three cases is still under investigation.

Of the 132 cases confirmed to date in Indonesia, 107 have been fatal.

http://www.who.int/csr/don/2008_04_02/en/index.html

Dr. Henry Niman was among the first to note that the brother of the 15-year old who died, had himself died earlier.  That death was attributed to dengue fever.  Strange that the first brother was not tested for H5N1, apparently.  Dr. Niman's commentary is below:

H5N1 Clusters and Denials Raise Indonesian Pandemic Concerns

Recombinomics Commentary 13:50
March 31, 2008

Kandun dismissed the possibility of more bird flu cases in the same family after the boy's brother died recently. Confirmed cluster cases raise concerns over human-to-human transmission. "It is not correct that there is a cluster in Subang," Kandun said, adding that the brother has died of dengue fever.

The above denial of an H5N1 cluster in Subang is cause for concern. Both brothers were initially diagnosed as dengue fever. However, since dengue fever is transmitted by insects, they likelihood of two fatal cases in the same family with distinct disease onset dates is remote. Consequently, the second case was tested for H5N1 and was positive, strongly suggesting that the index case was also H5N1 positive and infected his brother. The denial of the cluster by the director general of communicable disease control in Indonesia raises serious transparency problems, and is similar to denials of H5N1 in the first confirmed cluster in Indonesia, almost three years ago. Those cases were initially said to have died from bacterial pneumonia, although the father was subsequently H5N1 confirmed, and the H5N1 from that patient is a target for vaccines directed to clade 2.1, the clade of H5N1 in Indonesia. (bold mine)

In addition to the death of a family member of an H5N1 confirmed case in West Java, a similar cluster has been reported in the local media in Sumatra. H5N1 has been confirmed in a young child, but the recent death of a family member has not been reported in the English language press. Similarly, the nurse who cared for one or both family member is in isolation with bird flu symptoms, raising concerns of a expanding cluster.

The two clusters above, as well as a third confirmed case, located in Bekasi, which is near the two brothers in West Java, raises pandemic concerns. Although clusters in Indonesia are not new, the government denial of the cluster in West Java and the failure of the English press to recognize the cluster in Sumatra, raises concerns that the number of cases and clusters are significantly higher than the reported confirmed or suspect cases.

More information of testing in these two clusters would be useful. Dengue fever claims raise concerns that additional H5N1 cases are being mis-reported.

http://www.recombinomics.com/News/03...er_Denial.html

So two of the most recent H5N1 cases had family members who died suddenly at about the same time.   As I have maintained, in public health there are no coincidences.  The possibility that family members would die of different diseases in the same timeframe is remote and not nearly as plausible as the suggestion they all died from the same thing.  H5N1.  And if that were true, the number of family clusters in Indonesia is accelerating even more than we have previously confirmed.

Perilous times, indeed.  Perhaps the WHO should consider assigning different phases to different countries, the same way that Homeland Security assigns different warning colors to different sectors.  For example, today the US is at Yellow, while air travel maintains Orange.  Using that logic, who could possibly disagree that Indonesia warrants a Phase Four?