A ProMED-mail post
<http://www.promedmail.org&gt;
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org&gt;
In this update:
[1] Indonesia - the northern Sumatra cluster
[2] Indonesia - new suspected fatal case in West Java
 

The Indonesian health authorities and WHO have further strengthened
their response to the family cluster of cases in Kubu Simbelang
village, Karo District, North Sumatra. As of today  [Wed 31 May
2006], 54 surviving family members and other close contacts of cases
have been identified and placed under voluntary home quarantine. All
of these people, with the exception of pregnant women and infants,
are receiving the antiviral drug oseltamivir for prophylactic
purposes. Public health teams visit these people daily, checking for
symptoms.

In addition, active house-to-house surveillance for influenza-like
illness is being conducted throughout the village, which has around
400 households. A command post for fever surveillance has been
functioning in the village since last week.

As of today [Wed 31 May 2006], no new cases suggestive of H5N1
infection have been detected since 22 May. This finding is important
as it indicates that the virus has not spread beyond the members of
this single extended family. No hospital staff involved in the care
of patients, in some instances without adequate personal protective
equipment, have developed the disease. The last person in the
cluster, who developed symptoms on 15 May and died on 22 May, refused

hospitalization. He moved between 2 villages while ill, accompanied
by his wife. The wife is under surveillance and has not developed
symptoms.

Despite multiple opportunities for the virus to spread to other
family members, health care workers or into the general community, it
has not, on present evidence, done so.

Current level of pandemic alert
-------------------------------
Based on an assessment of present evidence, WHO has concluded that the current level of pandemic alert is appropriate and does not need to change. The level of pandemic alert remains at phase 3. This phase pertains to a situation in which occasional human infections with a novel influenza virus are occurring, but there is no evidence that
the virus is spreading in an efficient and sustained manner from one
person to another.

WHO has recommended continued close monitoring of the situation in
Kubu Simbelang for the 2 weeks following 22 May, the date when the
last known case in the cluster died. As a precautionary measure,
Indonesian authorities have decided to extend this recommended period to 3 weeks.

Preliminary results of the investigation
----------------------------------------
This information differs in some details from information released in
previous updates, but is derived from extensive investigations by
senior national and international epidemiologists, from WHO and the
US Centers for Disease Control and Prevention, who have developed a clearer picture of the situation. The cluster involves an initial case and seven subsequent laboratory-confirmed cases. All cases are members of an extended family: sisters and brothers and their children. Family members resided in 4 households, 3 of which were next-door neighbours in the village of Kubu Simbelang, Karo District, North Sumatra. The 4th household was located about 10 kilometres away in the nearby village of Kabanjahe.

The initial case in the cluster was a 37-year-old woman who sold
fruits and chillies at a market in the village of Tigapanah. Her
stand was located about 15 metres away from a stand where live
chickens were sold. The investigation uncovered no reports of poultry
die-offs in the market. However, the woman kept a small number of
backyard chickens, allowed into the house at night. Three of her
chickens reportedly died before she became ill. She is also known to
have used chicken faeces from these household chickens as fertilizer
in her garden.

A parallel agricultural investigation has not, to date, detected H5N1
virus in PCR tests of approximately 80 samples from poultry, other
livestock and domestic pets, and chicken fertilizer taken from the
vicinity.

The initial case developed symptoms on 24 Apr, was hospitalized on 2
May, and died on 4 May 2006. No samples were collected for testing
prior to her burial, but she is considered part of the cluster as her
clinical course was compatible with H5N1 infection.

The initial case had one sister and 3 brothers. The sister and 2 of
the brothers subsequently developed infection. The remaining cases
occurred among children in these families.

The confirmed cases include 5 males and 2 females with an average age of 19 years (range from 1 to 32 years). Of the 7 confirmed cases, 6
developed symptoms between 3 May and 5 May. These cases include 2 sons of the initial case, her brother from Kabanjahe, her sister, the
sister's baby, and the son of a 2nd brother living in an adjacent
house. This 2nd brother, the last case in the cluster, developed
symptoms on 15 May. Of the 7 cases, 6 were fatal.

Exposures
---------
On the night of 29 Apr, 9 family members spent the night in a small
room with the initial case at a time when she was severely ill,
prostrate, and coughing heavily. These family members included the
initial case and her 3 sons; the brother from Kabanjahe village, his
wife, and their 2 children; the 21-year-old daughter of another
brother (who did not become infected); and another young male visitor.

Following this event, 3 family members -- the woman's 2 sons and the
visiting brother from Kabanjahe -- developed symptoms from 5 to 6
days later.

The woman's sister, who lived in an adjacent house, developed
symptoms at the same time, as did her 18-month-old daughter. Prior to
symptom onset, this sister, accompanied by her daughter, provided
close personal care of the initial case.

The last case in the cluster provided close care for his son
throughout his hospital stay, from 9 to 13 May. The son was a
frequent visitor in the home of the initial case and was present
there on 29 Apr 2006.

--
ProMED-mail
<promed@promedmail.org>
[This statement supports the interpretation that limited
person-to-person transmission of H5N1 virus infection may be possibl
among close blood relatives, but as yet there is no evidence to
suggest that the H5N1 virus has acquired any of the characteristics
of a pandemic virus. - Mod.CP]

******
[2] West Java
Date: Wed 31 May 2006

From: Mary Marshall <tropical.forestry@btinternet.com>
Source: Yahoo News, Associated Press rep[ort, Wed 31 May 2006 [edited]
<http://news.yahoo.com/s/ap/20060531/ap_on_re_as/indonesia_bird_flu&gt;

Preliminary tests have found that avian influenza has killed another
person in Indonesia, as the country struggles to get a grip on a
spike in cases, a local health official said Wednesday [31 May 2006].
The latest victim was a 15-year-old boy from West Java who was rushed to a hospital in Bandung on Monday [29 May 2006] and died a day later, said Hariyadi Wibisono, Director of Communicable Disease
Control at the Ministry of Health. Local tests came back positive for
the H5N1 bird flu virus, but the specimens have been sent to a World
Health Organization laboratory in Hong Kong for confirmation, he said.
The boy, from the town of Tasikmalaya, had a history of contact with
poultry, he said. He is the 3rd recent victim from West Java. Last
week, a 10-year-old girl and her 18-year-old brother who lived in
another village died after being infected with the virus. Sick and
dead birds were reported near their home. The WHO has confirmed these results, bringing Indonesia's toll to 36.
--