Tuesday, May 16, 2006

Indonesian cluster: What, me worry?

The cluster of eight in Indonesia and the commenting on it here and elsewhere deserves a meta-comment.

In the early days of the H5N1 epizootic those of us paying attention seized on many signs that the character of disease transmission had changed. There have been other clusters and even more unconfirmed reports of hundreds of people falling ill in China and elsewhere. Each, taken separately, had some plausibility. Taken together, however, they tell a more cautionary tale.

This thing may go human to human at any time. Some believe it has already done so. And it may never do so. All of these are plausible and defensible positions. I am agnostic on the subject, although I think it is prudent to act as though it may go human to human at any time and that is the policy I've urged. Act as if it will and be glad if it doesn't.

One thing I've learned in many years as an epidemiologist is that disease outbreaks are rarely what they appear to be at first. Sometimes they are worse and sometimes they are better, but mostly they are different. I've spent a lot of years dealing with cancer clusters and I am a strong believer these clusters are real. But there is a school of thought that says they aren't and there is a strong argument to make there. I disagree with them, for technical reasons. The one thing I know about clusters, though, is that it is important to verify all the initial information. A large proportion of the time the cancers in a cancer cluster aren't even cancer, or they are a different kind of cancer than initially reported. Numerous other facts usually turn out to be different than originally thought .

So in the Indonesian cluster, as with other reports about bird flu that come to us from far away, filtered through media reports and machine translations, I now prefer to wait a bit and see how it shakes out. I didn't do that in the early days of the bird flu problem but I should have. I've checked the diagnoses with a source in-country and I'm satisfied it is H5N1. But the other information, like dates of onset, are always problematic, so I'm waiting to see what develops.

My personal opinion is that the Indonesian cluster looks like it is a possible instance of either increased bird to human transmission or an instance of human to human. These cases have occurred before, but the size of this cluster makes one ask if something has changed. Henry Niman derides the idea it is enhanced bird to human transmission on the grounds that bird flu is very hard to catch from a bird. True. There are millions of bird human exposures and very few human cases. On the other hand it is hard to catch from other people, too. So I'm not sure I understand Henry's point (although I am quite sure he'll tell me, in his usual gracious way).

So I'll continue to hold back a bit. A day or two here or there to get better information seems a reasonable investment that repays in sanity and a clearer head. Maybe this will turn out to be the start of human to human transmission. Maybe not. Or maybe it is but won't go any farther, as in other instances.

Watchful waiting seems indicated for those of us half a world away. In the meantime we can continue to try toget our communities ready in case H5, or H9, or something entirely different should appear. There's lots of things to do, but jumping on a horse and riding madly off in all directions doesn't seem like it should be one of them.