Thursday, September 29, 2005

Playing soon in a community near you?

Two more suspect bird flu deaths are being reported in Indonesia while a health ministry official in Jakarta is saying, on condition of anonymity, that there are now 63 confirmed or suspected cases under treatment or observation. This is higher than yesterday's report of 55 (or 53 or 57, depending on source and time of report). Thus the situation continues to evolve. Six of the cases have died, but the latest two would bring the total to eight, if confirmed. Meanwhile a second zoo in Semarang has been closed after tests on birds showed infection.

With events moving rapidly and the health ministry beleaguered it is difficult to get a clear picture of the true state of play. According to Agence France Presse (via ChannelNewsAsia), a usually reliable source:
Of the 63, six have died but further tests are still being carried out on the latest fatality to confirm that the victim died of the virus.

Some of those infected with the virus have not shown any symptoms and others have made a full recovery, officials said.

Bird flu has killed 43 in Vietnam, 12 in Thailand and four in Cambodia.

The health ministry official said that the 63 cases of bird flu could be broken down into three categories -- confirmed, probable and suspected cases.

A patient is suspected to have bird flu if the person showed clinical symptoms of the disease such as high fever, said Sardikin Giriputro, deputy director of Sulianti Saroso hospital, the main hospital treating bird flu patients.

Probable cases refer to those who have had initial tests that strengthened suspicion of infection, including X-rays showing that pneumonia had developed, he said.

Confirmed cases refer to cases which had been clinically and serologically tested positive, and had the results confirmed by the World Health Organisation through further tests in Hong Kong.

Only five of the 63 were confirmed bird flu cases, nine were probable cases, while the rest were suspected.
Meanwhile the Health Ministry struggles to cope with the growing sense of public unease and incipient panic. In such an atmosphere and with "flu-like symptoms" a vague category, it is likely there are many "worried well" consulting their doctors and visiting hospitals and clinics, as well as some who may be genuinely sick with bird flu. Unfortunately the desperate-appearing attempts to reassure will only promote further distrust of a government response that merits little trust:
The number of suspected bird flu cases in Indonesia rose to 48 today [sic] as the health minister appealed for people not to shun patients suffering from the virus, saying close contact with them was not dangerous.

Siti Fadili Supari was photographed in newspapers yesterday kissing a nine-year-old boy who had returned from a hospital where he was treated for bird flu after rumours spread in the neighbourhood that it was unsafe to get close to him.

Supari urged neighbours to go about their life as normal, saying that the virus could only be contracted from infected poultry, Kompas daily reported.

“This boy is proof that it is possible to fight bird flu,” Supari was quoted as saying. “He is a boy with muscles of steel and bones of iron.” (AP via Evening Standard
This AP report also gives another definition of "suspect" case, not present in the AFP report above:
Patients showing symptoms of the disease – including high fever, coughing and breathing difficulties – and who have been in recent contact with chickens are considered suspected cases in Indonesia.
If this is indeed the Health Ministry's suspect case definition (we cannot tell from this news report where it came from), the lack of evidence of person-to-person transmission may be a result of what epidemiologists call selection bias, in essence a self-fulfilling prophecy. The attempt by the Health Minister to prevent the shunning of those who are sick is admirable but hugging those who are ill is not. People need reasonable guidelines about how to care for those who are ill in ways that don't needlessly endanger the care-givers while still allowing the humane attendance that will promote survival and recovery. Masking the sick patient and the care-giver and reasonable hygiene (handwashing and not going out with clothing contaminated with blood, mucus or secretions from the sick) is minimally achievable advice that should be promoted, not embracing potentially infective individuals.

The Indonesian Health Ministry response is improvised, unthought-out and borne of confusion and panic. Unfortunately, they are not much worse off than many of their counterparts (including the US) because of a studious lack of preparation at the local level by the governments involved.

Take a good look at Indonesia because it will be a preview of what's to come wherever you are.

Addendum, WHO Case definition (.pdf) ; thanks to Declan Butler; elevated from Comments:
Possible influenza A/H5 case

i. Any individual presenting with fever (temperature >38°C) AND one or more of the following symptoms:

cough; sore throat; shortness of breath;


one or more of the following:

a. laboratory evidence for influenza A by a test that does not sub-type the virus;
b. having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious*;
c. having been in contact during the 7 days prior to the onset of symptoms with birds, including chickens, that have died of an illness;
d. having worked in a laboratory during the 7 days prior to the onset of symptoms where there is processing of samples from persons or animals that are suspected of having highly pathogenic avian influenza (HPAI) infection.


ii. Death from an unexplained acute respiratory illness


one or more of the following

a. residing in area where HPAI is suspected or confirmed;
b. having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious*.

Probable influenza A/H5 case

Any individual presenting with fever (temperature >38°C)


one or more of the following symptoms:

cough; sore throat; shortness of breath;


limited laboratory evidence for Influenza A/H5 (H5 specific antibodies detected in a single serum specimen).

Confirmed influenza A/H5 case

An individual for whom laboratory testing demonstrates one or more of the following

a. positive viral culture for Influenza A/H5;
b. positive PCR for Influenza A/H5;
c. immunofluorescence antibody (IFA) test positive using Influenza A/H5 monoclonal antibodies;
d. 4-fold rise in Influenza A/H5 specific antibody titre in paired serum samples.