Good news, bad news on Indonesian bird flu front
Scott McPherson
in Politics and government, influenza and infectious diseases
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3 Comments
There was good news contained within the bad news coming from Indonesia this week. The good news was that Indonesia will, indeed, continue to report bird flu deaths within some sort of usable timeframe. As you recall, the Health Ministry had decided not to publish bird flu deaths within helpful timeframes but, instead, to roll up the death tolls and announce them on some sort of months-long schedule.
While I am not ready to call this week's announcements a reversal, it is welcome news and hopefully will eventually be proven to be a reversal of a disastrous policy.
The bad news, of course, was the announced new death toll, and in particular the deaths of two women. The Health Ministry confirmed what we already suspected was an H5N1-related death -- a 16-year-old girl from South Jakarta -- who was confirmed dead of H5N1 on May 14. the second death was a 34-year-old woman from Banten province, who was pronounced dead on June 3.
The virus continues to strike lethally at younger persons, and women continue to be especially hard-hit.
The next story also confirms our deepening concern about the status of things in the archipelago nation of 18,000 islands. A Reuters story of today validates/vindicates our belief that H5N1 is frequently and dangerously diagnosed as something other than flu. Thus, we can assume rationally that the actual infection rates from H5N1 are many times higher than what has been reported. Here's the story:
Bird flu mistaken as dengue and typhoid in Indonesia
By Tan Ee Lyn
KUALA LUMPUR (Reuters) - Some cases of human bird flu in Indonesia have been variously misdiagnosed as dengue fever and typhoid, resulting in the late administration of drugs, a leading doctor in the country said on Friday.
Indonesia has had the highest number of human H5N1 cases in the world and while mortality rates are around 60 percent in other places, the figure is highest, or at 81 percent, in Indonesia.
Sardikin Giriputro, director of the Sulianti Saroso Infectious Disease Hospital in Indonesia, told an infectious disease conference in Kuala Lumpur that misdiagnoses and the late administration of drugs were partially responsible for the high mortality rates.
"It (H5N1) is misdiagnosed initially as dengue, bacterial pneumonia, typhoid and upper respiratory tract infection because of similar clinical features (symptoms)," Giriputro said.
Indonesia has had 135 confirmed human H5N1 cases from late 2003 to May 2008 and 110 resulted in deaths. The country reported two more confirmed cases this week, but these were not reflected in Giriputro's figures.
Oseltamivir, otherwise known by its brand Tamiflu, is considered the drug of choice against bird flu and Giriputro said fatalities mounted the later the drug was administered.
The survival rate was very high when Tamiflu was given less than 2 days after the onset of symptoms, but that plunged the later the drug was given.
"It's best if given less than 24 or 36 hours after the onset of symptoms," he told Reuters later.
While rapid test kits are now used to diagnose the disease in animals, Giriputro said these tools were much less reliable in people.
"It depends on the viral load (in samples taken from patients)," he said, adding that test results could turn out negative even if the person was infected with H5N1, simply because there was not enough virus in samples taken. (bold mine)
In a bid to reduce the death rate, the Indonesian government has begun distributing Tamiflu to health centers in areas where H5N1 cases have occurred.
"When doctors see influenza-like illnesses and where there is evidence of contact with sick poultry, then they give Tamiflu (without waiting for laboratory results)," Giriputro said.
http://in.reuters.com/article/health/idINKLR31511520080620?pageNumber=2&virtualBrandChannel=0
Dr. Henry Niman and others have warned for years that the hasty administration of Tamiflu without first taking necessary samples causes false negatives and hinders accurate reporting of human H5N1 cases. This new report from the Boots On The Ground confirms this in a decisive and final way. It lessens the viral load and allows H5N1 to "fall under the radar" of reporting. Likewise, Dr. Giriputro has also declared -- on and for the record -- that quick test kits are unreliable for use as the "last word" on whether or not H5N1 is present in someone.
So what can we deduce from all this?
First, there are many, many, many more unreported cases of human H5N1 than we see in the press. This may be a "DUH" to us, but it is important to see this in the global media. And it is equally important that we are vindicated in that venue as well.
Second, we are unable to get some important viral changes mapped, because these people are getting Tamiflu and testing negative. that may be good in terms of living, which is always nice, but it does mean that any genetic changes in the virus from these people are going undetected.
Third, Indonesia is a human incubator of H5N1, and we must continue to monitor the situation there 24/7/365, preferably with the full assistance of the Indonesian government.
Reader Comments (3)
The good news is the Reuters one isnt' a news at all. Previously, in Thailand Dengue Hemorrhagic Fever was initially diagnosed in a H5N1 patient and in Vietnam at early stage of epizootics some of human cases were misdiagnosed as dysentery due to predominance of GI symptoms. If a large, uncontrolled fatal disease is spreading in Indonesia you would see HCWs flying away from hospital as happened in Ebola outbreaks settings and in India Surat plague outbreak.
One can continue to say that H5N1 in Indonesia has reached pandemic proportion and no one may argue against. Well. But one should also add that this scenario is far for being real.
In the same ICID meeting interview with Indonesian doctor, it is stated that no mild cases or seroprevalence were noted to date.
Further, sat images may spot large movement for mass graves build or fire to burn corpses...
Please, if you want to say that a pandemic is ongoing in Indonesia you are well in right to do it, but you are sure of the usefulness of this behaviour?
I don't think he was saying that a pandemic is starting, and I agree that this story doesn't imply that. What's concerning is that Indonesia is being extremely negligent in tracking the spread of H5N1, and that WHO isn't doing nearly enough to get them in shape. Nonetheless, it's good to have stories like this in the media, since it draws more attention to these problems. Let's hope it continues.
CUT THE CHAIN OF INFECTIONS !
Spread of avian flu by drinking water:
Proved awareness to ecology and transmission is necessary to understand the spread of avian flu. For this it is insufficient exclusive to test samples from wild birds, poultry and humans for avian flu viruses. Samples from the known abiotic vehicles also have to be analysed. There are plain links between the cold, rainy seasons as well as floods and the spread of avian flu. That is just why abiotic vehicles have to be analysed. The direct biotic transmission from birds, poultry or humans to humans can not depend on the cold, rainy seasons or floods. Water is a very efficient abiotic vehicle for the spread of viruses - in particular of fecal as well as by mouth, nose and eyes excreted viruses.
Infected birds and poultry can everywhere contaminate the drinking water. All humans have very intensive contact to drinking water. Spread of avian flu by drinking water can explain small clusters in households too. Proving viruses in water is difficult because of dilution. If you find no viruses you can not be sure that there are not any. On the other hand in water viruses remain viable for a long time. Water has to be tested for influenza viruses by cell culture and in particular by the more sensitive molecular biology method PCR.
There is a widespread link between avian flu and water, e.g. in Egypt to the Nile delta or Indonesia to residential districts of less prosperous humans with backyard flocks and without central water supply as in Vietnam: http://www.cdc.gov/ncidod/EID/vol12no12/06-0829.htm. See also the WHO web side: http://www.who.int/water_sanitation_health/emerging/h5n1background.pdf .
Transmission of avian flu by direct contact to infected poultry is an unproved assumption from the WHO. There is no evidence that influenza primarily is transmitted by saliva droplets: “Transmission of influenza A in human beings” http://www.thelancet.com/journals/laninf/article/PIIS1473309907700294/abstract?iseop=true .
Avian flu infections may increase in consequence to increase of virus circulation. In hot climates/the tropics flood-related influenza is typical after extreme weather and floods. Virulence of influenza viruses depends on temperature and time. Special in cases of local water supplies with “young” and fresh H5N1 contaminated water from low local wells, cisterns, tanks, rain barrels, ponds, rivers or rice paddies this pathway can explain small clusters in households. At 24°C e.g. in the tropics the virulence of influenza viruses in water amount to 2 days. In temperate climates for “older” water from central water supplies cold water is decisive to virulence of viruses. At 7°C the virulence of influenza viruses in water amount to 14 days.
Human to human and contact transmission of influenza occur - but are overvalued immense. In the course of influenza epidemics in Germany, recognized clusters are rare, accounting for just 9 percent of cases e.g. in the 2005 season. In temperate climates the lethal H5N1 virus will be transferred to humans via cold drinking water, as with the birds in February and March 2006, strong seasonal at the time when drinking water has its temperature minimum.
The performance to eliminate viruses from the drinking water processing plants regularly does not meet the requirements of the WHO and the USA/USEPA. Conventional disinfection procedures are poor, because microorganisms in the water are not in suspension, but embedded in particles. Even ground water used for drinking water is not free from viruses.
http://www.un.org/apps/news/story.asp?NewsID=26096&Cr=&Cr1
Ducks and rice [paddies = flooded by water] major factors in bird flu outbreaks, says UN agency
Ducks and rice fields may be a critical factor in spreading H5N1
26 March 2008 – Ducks, rice [fields, paddies = flooded by water! Farmers on work drink the water from rice paddies!] and people – and not chickens – have emerged as the most significant factors in the spread of avian influenza in Thailand and Viet Nam, according to a study carried out by a group of experts from the United Nations Food and Agriculture Organization (FAO) and associated research centres.
“Mapping H5N1 highly pathogenic avian influenza risk in Southeast Asia: ducks, rice and people” also finds that these factors are probably behind persistent outbreaks in other countries such as Cambodia and Laos.
The study, which examined a series of waves of H5N1 highly pathogenic avian influenza in Thailand and Viet Nam between early 2004 and late 2005, was initiated and coordinated by FAO senior veterinary officer Jan Slingenbergh and just published in the latest issue of the Proceedings of the National Academy of Sciences of the United States.
Through the use of satellite mapping, researchers looked at a number of different factors, including the numbers of ducks, geese and chickens, human population size, rice cultivation and geography, and found a strong link between duck grazing patterns and rice cropping intensity.
In Thailand, for example, the proportion of young ducks in flocks was found to peak in September-October; these rapidly growing young ducks can therefore benefit from the peak of the rice harvest in November-December [at the beginning of the cold: Thailand, Viet Nam, Cambodia, Laos are situated – different from Indonesia – in the northern hemisphere].
“These peaks in congregation of ducks indicate periods in which there is an increase in the chances for virus release and exposure, and rice paddies often become a temporary habitat for wild bird species,” the agency said in a news release.
“We now know much better where and when to expect H5N1 flare-ups, and this helps to target prevention and control,” said Mr. Slingenbergh. “In addition, with virus persistence becoming increasingly confined to areas with intensive rice-duck agriculture in eastern and south-eastern Asia, evolution of the H5N1 virus may become easier to predict.”
He said the findings can help better target control efforts and replace indiscriminate mass vaccination.
FAO estimates that approximately 90 per cent of the world’s more than 1 billion domestic ducks are in Asia, with about 75 per cent of that in China and Viet Nam. Thailand has about 11 million ducks.
Dipl.-Ing. Wilfried Soddemann - Epidemiologist - Free Science Journalist soddemann-aachen@t-online.de http://www.dugi-ev.de/information.html