last thread is here. when they get too long, they slow the site.
More news:
16/05/2006 07:39
Liputan6.com, the Karo Land: Hundreds Of villagers the Simbelang Fortification visited the Regent’s Hall the Karo Land, North Sumatra, on Monday (15/5). They asked for the upper assurance of lack of clarity of the endemic matter of bird flu that fell on their village of the government statement. This was resulted in after five from his eight villagers positive suffered the virus H5N1. The action was held because of lack of clarity of the matter of the government statement cluster bird flu that struck villagers the Simbelang Fortification. Because the statement made results of the Simbelang plantation of the Fortification Village be not accepted in the other area. The citizens that most groups of the mother and children this asked for proof produced by the laboratory of the Health of the matter of the Body of the Department’s Research And Development cluster the bird flu [read: Cluster in the Karo Land that most Big]. In this action, the tension could happen when the Regent the Karo D. D. Sinulingga Land gave the explanation. The demonstrators also urged the local regent to carry out anticipation of the bird flu virus in the Simbelang Fortification Village that up to now still not is carried out. (ZIZ/Tim Coverage 6 SCTV)
http://www.liputan6.com/view/7,122904,1,0,1147749777.html
West Java outbreak in poultry. In a area that had been vaccinated? 16/05/2006 08:55
Liputan6.com, Sukabumi: a Year pascamerebak him the case of bird flu in Sukabumi, West Java, several poultries belonging to the breeder many that died suddenly. According to the official of public relations of the World of the Health Body (WHO) the P. Setiogi Main Point, this condition was caused to not yet understand him the breeder overcame the eradication of the plague of bird flu maximally. “That was the people’s livestock breeding and small that where the vaccination did not yet go well.” Even so with the cleaning of the pen, said the Main Point when visiting poultry livestock breeding in Sukabumi, recently. In 2005 set, hundreds of thoroughbred chickens were in Sukabumi attacked by the bird flu virus. According to the Sukabumi Livestock Breeding Service, more than 2. 000 thoroughbred chickens died as a result of the virus attack avian influenza. Now the poultry farm talk to in the Tenjolaya Village could be maintained as the source of the spread of the virus H5N1 after around 1. 400 chickens died suddenly. Was based on results of the WHO survey, several poultries still many that were found died suddenly in several centres of poultry livestock breeding in several Indonesian territories. To overcome the spreading of this deadly virus, WHO promised to help mensosialisasikan the prevention method and the control of the virus H5N1 in the level of the subdistrict and the village all over the Motherland. (ZIZ/Heru Budi and Wisnu Murti)
CLUSTERS AND THE MEDAN AIRPORT
I notice Medan, Indonesia has an airport that flies to international destinations. Does anyone know what plans, if any, are in place to monitor air travel out of Medan. With rumors of up to 50 or more people being ill with suspicious symptoms, if this outbreak is h2h then there may be a need to pay close attention to these outgoing flights. And, if as has been suggested, other people with the virus may be staying away from public health facilities and possibily infecting others who also remain under the radar, this airport issue becomes a significant concern.
Good point. There is also daily ferry service from Medan to Penang, Malaysia; human cases in that country would likely serve as an early warning of a bigger, underlying problem in Sumatra
Reposting because some people may not wait for thread5 to fully load, and I just posted it there before they announced they were moving here (*sigh*)…
O.K. I do have someone that I know through the Avian Flu Watch group I had created on Flickr about a year ago now, who had said:
“I’ll help you in that area. I can speak a bit of Bahasa Indonesia.” (mind you, this was about 8 months ago).
I have sent him messages via his flickrmail and email accounts tonight. Hopefully his offer still stands :-)
If you want to check out his blog (he’s an utterly FANTASTIC photographer) he’s here: JavaJive
Well, I hope these travel hubs are being closely watched. It certainly is becoming clear why the experts have been concerned about Indonesia. And it is strange to see so many wire stories about how the virus may have abated right now, while this Medan outbreak threatens in such an alarming way.
Melanie,
Sorry I didn’t respond sooner. Not sure what you wanted my judgement on, though. In general, I’m still concerned. Not enough information yet to say whether this yet another dead-end cluster or the start of something. I get the impression the WHO is concerned. Turkey-type cluster or worse.
DennisC,
Primers are short, usually about 20 nucleotides long. There are two primers. They flank the area that will be amplified in the PCR (polymerase chain reaction). Once you amplify a segment of the virus, you check the size on an agarose gel or sequence the product to be certain of what you have. A mismatch in either primer can cause the PCR to fail resulting in a false negative.
«Watching and Learning – at 23:44 --- With rumors of up to 50 or more people being ill with suspicious symptoms»
Have the rumors been that they are ill with suspicious symptoms or that they are just being tested by WHO for the virus. That might sound like a silly distinction, but I was wondering if they were testing people that had had close contact that might still be well or only sick people. Can you test for the virus after exposure but before symptoms start??
Watching and Learning “With rumors of up to 50 or more people being ill with suspicious symptoms”
I’ve been trying to find the reference to that but failed. Can you give us some link or where you got it?
I just saw that Andrew Jeremijenko posted this over at Effect Measure
What I find most disturbing about this case was the fact that the suspect bird flu cases were allowed to leave the hospital. If this had been a test on whether Indonesia could control a pandemic virus Indonesia just failed the test.
At the moment there appears to be no more cases in Medan identified which is slightly reassuring, but with limited surveillance one must be cautious in interpreting this.
If you read the Media Indonesia post at http://www.mediaindo.co.id/ regarding this cluster (I have translated from Indonesian for you) it states that
“according to NG (family member) because of the bad services provided to the 2 suspect flu cases (TG 35 yo, JG 25 yo)they left the hospital on Thursday 11 May. “From entering the hospitals from afternoon to evening there is no maximal treatment. The patients were placed in the same room as another patient in a bad condition. While these patients were not yet bad.” said NG. Because his condition worsened, JG (suspect bird flu case) on Saturday 13th May finally returned to the hospital While TG is not yet known where she was taken care of after leaving hospital.”
(In Kompas newspaper, TG went to another hospital Mt Elizabeth)
Thus both suspect flu patients returned to the community while febrile and sick and could have spread the virus widely if it had efficient human to human transmission. It is hoped this is not the case.
Andrew Jeremijenko comment at Effect Measure
Dr. Jeremijenko was associated with NAMRU-2, the US Navy lab that was testing for H5N1 in Indonesia. Not clear what their role is now.
I am searching for the link for you. I think was in one of the wire pieces I read today and caught my attention because of the larger number of people being observed with flu-like symptoms. Definitely not a WHO report.
This might be the link Watching and Learning is referring to that mentions 57 blood samples. These are only samples.
Translation: difficult to understand Medan — MIOL: the North Sumatran Health Service (North Sumatra) has sent 57 samples of blood to Hong Kong to be checked resulting from the existence of the assumption of bird flu in Medan.The sample of the blood results of clinical investigation from the Simbilang Fortification Village, the Subdistrict of three bows, to the hospital in Kabanjahe, the Karo Land Regency and the hospital in Medan.”Up to now, the Government of the North Sumatran Province has sent 57 samples of blood that was taken from the family, the midwife, and the nurse.”If 57 samples were it was said positive bird flu, significant this was the disaster for North Sumatra.We prayed, hopefully not, the North Sumatran headword of the Health Service, Fatni Sulatni in konfrensi the press in RSU Adam the Owner, Medan, on Monday (15/5).Moreover, up to now still could not be confirmed the source of the spread of the illness was expected by bird flu in the Sembilang Fortification Village, the Subdistrict of three bows, the Karo Land Regency that has caused six people to die.This was shown with adaya results of the negative of the sample of the poultry and fertiliser that came from this village that was checked by the North Sumatran Livestock Breeding Service.Whereas to to six patients who have died, their status increased from suspect to probable (possibly) bird flu.To be stated pnyakit this was bird flu, the local regional government was still being waiting for results of the sample of Hong Kong.Fatni also said, if positive results, meant to have the extraordinary incident, that had the right to announce the official of the echelon i the Department of the Health.In the meantime, two patients suspect bird flu that still was treated in RSU Adam the Owner and RS Elisabeth Private Enterprise that is Jonnes Ginting, 25 and Obviously Ginting in the condition that began to improve.”Was based on the photograph thorax finally, to the Jonnes Ginting lungs, was seen by the spreading of pneumonia began to decrease.”Beforehand his spreading was very wide.Expected to this patient to be able to recover, said the Chairman Tim the Control of bird flu in RSU Adam the Owner, Dr Luhur Soeroso.
I apologize if this posting is out of order or a copyright issue.
Monotreme-Jakarta cut their own throat and ordered Namru-2 closed effective 31 December, 2005, unless a new memo of understanding was signed (although we’ve been operating there without one since 2000). Can’t find where that’s happened.
Well, shoot, I cannot find the story. And I don’t think it was the one posted above by Numbersgal. So, best ignore my “rumor” reference for now. I’ll post the link if/when I find it.
I can tell you about the major Travel.
Indonesia to Singapore - the whole world Indonesia to Penang Via Boat - Penang - KL International Airport Indonesia to CHina Indonesia to Singapore Via Boat
I mean it is Sustained H2H it can not be contained and could be all over.
I had it formatted but the site changed it
Thanks Numbersgal. Let’s hope those samples turn out to be negative.
Nidaho, I agree. If it’s respiratory, it’s over. We should know by the end of the week.
yes if it is H2H it will be easy to tell. I dont think it is yet, if so Sinapore would have shut the Airport.
Hi … casual bird flu watcher here .. have been waiting for reports of confirmed H2H clusters before doing a frantic 3-month supply buy up. Do you think this is the ‘go signal’. Should I wait a few days to see what eventuates? I live in New Zealand.
Oh, I think it’s H2H, but not necessarily efficient. Bodily secretions can spread a virus to alot of people.
I think there have been many H2H clusters, but they stopped because transmission wasn’t efficient enough. My guess for the mode of transmission is fecal-oral. That could be true here as well. If the mother prepared food while she was shedding virus she may have infected a large number of people. Think norovirus.
Fecal-oral won’t start a pandemic though. I think the key issue is how is the virus being spread in Indonesia now. If it’s respiratory, I think that’s the ballgame. Not enough evidence yet to say one way or the other.
As far as Singapore closing their airport, that’s a good point. Presumably countries in the region are monitoring the situation closely. However, once one acts, everything happens very fast.
Advice please,
I think there have been many H2H clusters, but they always have stopped. The question is not H2H, it’s is it H2H2H2H…
We don’t know yet.
Advice please – at 01:50
Hold your run….the next day or two will tell. Clusters are becoming more common these days, should it become something more you will know well in advance of the average person by watching this and other BF sites.
I agree that we will be the first ones. I’d be happy with a two hour head start to my local stores.
http://www.airasia.com/skylights/cgi-bin/skylights.cgi - select origin as KLIA & destination as Medan & u’ll be able to see the numerous almost daily flights & cheap airfares.
Air Asia is Malaysia’s only budget airline which is extremely popular for its dirt cheap airfares. Flies to Medan & from KL International Airport (KLIA) almost daily. Medan is a tourist destination with main attraction being Lake Toba.
We’ve a huge population of Indonesian migrant (legal & illegal) workers mostly in construction & labour intensive jobs (male) & full-time housemaids (female), esp. in the capital & adjacent large city & suburbs.
Thanks to all who’ve offered heartfelt prayers & well-wishes.
Tourism attraction Lake Toba - as in the Toba super volcano?
That island has had practice in originating disasters, hasn’t it though! What an irony if now…
Aziraphale at 03:08 - Yes the very one Toba super volcano.
Mamypoko – at 02:58
Thank you so much for the travel link and the explanation of the migrant worker situation where you live.
Are there any news articles in your area that share the same concerns that are expressed here over the deaths of the family members and of the 57 blood samples being tested? I see where Numbersgal – at 00:55 had done an automatic translation on that news.
It was so calming for everyone and such a relief yesterday to have you translate. It was greatly appreciated! I think the group had been doing a fine job interpreting the news, and you definitely confirmed that.
Most of the people here know what it is to have a child who is sick and how hard it is to work at the same time. Your time is precious and we appreciate you sharing it with us. G.
Monotreme – at 00:18 Thanks again, So they are checking 40 ( two 20′s) base pairs out of something like 2000. If it mutates in the unchecked part then we still get good matches, but if it happen to mutate in those specific 40, then it might mess up the test. I hope I got that right. And again thanks for teaching.
The question is what will the inevitable efficient H-H present like.
I would expect we would see an outbreak of several hundred people that would at first be misdiagnosed as probably Dengue fever. It would probably take more than a week to realize that it might be H5N1 and the testing would take another week with the WHO blocking release of information until the UN and all UN governments being notified.
By the time the WHO finally releases the information the pandemic will be on and already in several other countries.
I would expect this outbreak to occur in the fall/winter 2006/2007.
The point is there are real consequences in the near future to their unbroken habit of hiding information from objective scrutiny.
DennisC, they are checking for a subsegment of a gene. PCR products are usually 100–660 nucleotides long. The primers flank the area that is to by amplified by the polymerase. They anneal to virus nucleotides, the template. A polymerase causes the area in between the primers to be copied. This process occurs over many cycles resulting in many copies of the area in between the primers. You don’t have to know what the sequence is between the primers ahead of time, but if you use the wrong sequence information to pick the primers, they may fail.
Since influenza is a RNA virus, the RNA must be converted to cDNA before you can do the PCR. An enzyme call reverse transcriptase (RT) is used to do this. Hence, the whole process is called RT-PCR. There’s also a relatively new technique called Real Time PCR that can give you quantititative results very quickly. There are assays that can identify H5N1 infection within 5 hours.
Here’s some references.
Specific detection of H5N1 avian influenza A virus in field specimens by a one-step RT-PCR assay
Development of diagnostic capabilities for influenza H5N1 isolates
“The question is what will the inevitable efficient H-H present like.”
Is it possible that different presentations could form unrelated to one another? For example, one from Africa and one from Indonesia?
I understand that subsequent waves are likely mutations from the first wave, but could we have overlapping waves of different strains? And could they reassort between each other?
Monotreme – at 09:59
Thanks for the links - I now have info to do my homework.
Will. That is a very good point. Given the geographical spread it is entirely possible for multiple pandemic strains circulating at some later point.
There are also other influenza subtypes capable of spinning off a pandemic as well…
…but it seems that the initial strain will come out of Asia and probably China (Guandong) as the environment for the rapid development of a pandemic strain is most conducive there.
Possible Roumanian Human Bird Flu
http://www.iii.co.uk/news/?type=afxnews&articleid=5644716&subject=general&action=article
BUCHAREST (AFX) - A young Romanian woman showing bird flu-like symptoms has been admitted to the contagious diseases hospital in Bucharest, the hospital’s director Adrian Streinu-Cercel said.
The 25-year-old woman, who “has respiratory problems”, comes from Sita Buzaului, a village in central Romania where bird flu is suspected, Streinu-Cercel said.
Romanian health authorities are on the hunt for several dozen tonnes of chicken products produced at a farm in Codlea, central Romania, where the deadly H5N1 strain of the flu was found last weekend.
They fear the virus may have contaminated chicken products shipped to supermarkets.
The scare comes as the eastern European country awaits a decision Tuesday from Brussels about joining the European Union, with EU officials already worried about food safety in Romania.
Bird flu has been confirmed at 56 sites in Romania since the disease first surfaced last October in the country’s Danube delta.
There have so far been no confirmed cases of it spreading to humans. newsdesk@afxnews.com afp/har
COPYRIGHT
Copyright AFX News Limited 2005. All rights reserved. The copying, republication or redistribution of AFX News Content, including by framing or similar means, is expressly prohibited without the prior written consent of AFX News.
AFX News and AFX Financial News Logo are registered trademarks of AFX News Limited
Advice one- why wait? if you wait until the last minute, there could be thousands trying to prep as well.
Hey - Quick Request for someone who’s been involved in this news topic since the get go - Could someone summarize what’s been going on with this cluster?
I can only visit every once in a while and it’s like one of those “flip-books” where you can see a “movie” if you see all of it - otherwise - if you look at it one page at a time you never see the motion…
Any way we can create a summary article on the main page? SOmething like the update/summaries that used to be at the start of the daily news threads…
Am I the death to threads or what?
:)
SO I assume the answer is.. “Wait till it’s on the ‘Clusters’ page?”
Regarding the 57 samples sent to Hong Kong, it’s possible that WHO and the Indonesian gov’t decided to skip testing in Jakarta. In other words, those 57 samples sent to Hong Kong are not automatically positive. If I was on the ground monitoring a cluster and rumours of H2H, why would I add another step into the process? Why not just swab those who had contact with the victims or were exhibiting symptoms and send the samples directly to the more reliable (?) WHO labs? Also, I believe that a lot of this testing is simply precautionary - which is a good thing.
quartzman 12:33 ‘fraid that title may belong to me…
on that note, if it isn’t the volvano that squashes any news, it could be this new earthquake!
will we ever know?
Quartzman: Nobody is sure what is going on. We have big cluster, a big enough cluster that some are surmising that MAYBE the virus has further evolved. We are all just waiting for the next shoe to drop OR to breathe a sigh of relief two or three days from now. Personally I am trending towards the latter at this point.
The United Nations needs to clean up Indonesia (and Africa), otherwise we will be revisiting this recent experience. And the outcome may not be the same.
banshee – at 12:33
You and a lot of other folks probably do will not like my theory on this, but here it goes.
If you skip testing in Jakarta (if that is what has happened) then you prevent the leaking of earth shaking news within your own country. If you send it to Hong Kong, and the WHO has a tight grip on the results of the sample analysis, then you can keep give yourself a wider window of action before the proverbial fan starts turning full speed.
This is not to say that the sample results are or will be positive for H5N1, but it may be indicative of the concern of the Indonesian government and the WHO.
banshee. I don’t think any testing is reliable other then paired blood samples showing an increasing titer to H5N1…too many false negatives on several levels of testing.
Realistically, there is no way to effectively monitor the goings on in Asia and probably in other parts of the world as well. To rely on it to provide warning is folly.
They should forget the testing and rely on patterns of symptoms..clinical signs. Identifying the difference between this disease and others in Asia will be the real difference.
Oops, my post got eaten so I’ll try again…
I will start tomorrow’s news thread with a summary of new and pending BF cases. I won’t be able to summarize the other reports but will try and organize the case reports.
Heather frantically searches for her son’s Dumb Bird Joke book…
…and jumps into the sandbox for some much needed practice…
Quartzman, this is the best summary I have seen thus far, Pro-Med link posted on todays’s news thread by bird-dog
Tom DVM, They HAVE to do testing. I really don’t think they can look for patterns in clinical signs. There are so many people in SE Asia with a variety of respiratory diseases. Testing is inconvenient but it is the only method available at this time to distinguish H5N1.
Okieman, Sure, anything is possible. But what is the most logical? I agree that the decision to send the samples directly to Hong Kong is indicative of concern. This is a large cluster, concern is appropriate. When one is concerned, one is willing to take extra precautionary measures - as they should. Still, it doesn’t mean that those 57 samples were positive or that they were even exhibiting symptoms. They were concerned so they took extra precautions.
Regarding WHO suppressing information, why try to cover up if a pandemic is brewing? It’s a futile exercise. In the coming weeks, as more cases popped up, people would figure it out. Besides, if a pandemic occured, I don’t think I would want to be the one to sit in front of the UN and explain why I covered up information. Sorry, it just doesn’t make sense to me.
banshee. Sorry, in this situation you do the testing…you just don’t rely on any of the results…this is not an unusual situation to be in with respect to testing.
Tom, I think I might have misunderstood what you were trying to say. Are you worried about people exhibiting symptoms yet you think their tests are false negatives?
banshee. Yes, there are and will be a high number of false negatives which means that the person has H5N1 but tests negative. In the case of a developing pandemic misdiagnosed as another disease such as dengue fever, the negative result would be misleading and give regulators a false sense of security.
I ask…how many members of the WHO have discussed the potential of false negatives…none that I know of…just because you invent a test does not mean it works…just because you invent a vaccine does not mean it works…just because you invent a treatment does not mean it works…it the world did work that way, things would be a lot easier.
In a sense, we must rely on the way things worked before all this technology was supposedly developed so that we no longer had the need to think.
The only effective test is paired serology and even then sometimes you can get false negatives.
banshee,
One or two days notice would allow a government to quarantine an area of the country. On the flip side, if news leaked out of a lab in Jakarta, (such as a lab worker with family in N. Sumatra and wanted to get them out before a quarantine), then the movement of people from the area would rapidly become unmanageable.
By sending the samples to Hong Kong, then you get more reliable results and prevent panic if there are false positives. And if the results are postive for H5N1 then you have some time to act before everyone starts bugging out of the country or off the island.
Please note the last sentence of my previous post:
“This is not to say that the sample results are or will be positive for H5N1, but it may be indicative of the concern of the Indonesian government and the WHO.”
I did not say that they were positive or that the people were exhibiting symptoms. It may just indicate the level of concern, and the need to get quick, accurate results, with some control over those results.
I remember they sent a large group of samples from Turkey to London to be tested…43 I think… and it took a few days before we learned that locally they tested negative first, but they sent them to be sure. Maybe that will be the case here. If there were already positives identified, don’t you think these peopel would be confined to the hospital or quarantined by now? We would have heard somethign from the media. The media is horribly inacurate, but we did hear news pretty quickly once attention was drawn to the cases. I’m sure if anyone that was suspected of H2H from the original family cases was checked into the hospital, we would have heard by now.
Lets hope the samples do not get conviently lost or contaminated !
Tom, I would be very suprised if WHO does not talk about false negatives behind closed doors. However, there is no way that nations will take actions (like closing airports or even borders)on “we THINK these cases were H5N1 but we can’t necessarily prove it.” This is just reality and how it works whether we like it or not. Also, I don’t think any regulators have any sense of security about this. I think all of us want to see the potential pandemic as it pops up on the horizon. But, considering that the only data we have to go on are media reports and maybe an occasional tip from an insider, I don’t really think that we will be able to identify a pandemic in its infancy. When you start seeing dozens or hundreds of confirmed cases, then I think we could make some inferences. This is a fact that we all need to get used to. Despite fluwikians vigilance, it is possible we will still get blindsided.
banshee: If we ever get UNCOMFIRMED reports (not lab-tested, but good eyewitness accounts of symptoms,etc.) of dozens, I think all who are going to “lock down”, should lock down, at least temporarily. One or two “false-positives” on the part of us preppers would be better than one “false-negative” that catches us out in a crowd.
MM, Everyone needs to assess their own situation and decide when they feel it is necessary to take action. However, I stand by my statement that I think we can be blindsided simply because many of the surveillance systems around the world are so weak. I think there are many things individuals can do to mitigate the risks of pandemic flu. However, I don’t think we can eliminate that risk entirely. Uncomfortable, but true. My purpose of responding to some of these posts is simply to point out that we have to be careful when making inferences from media reports and rumours. And as much as we may not like it, WHO and individual nations are the ones with boots on the ground and they have access to much better data. Also, I see a lot of WHO bashing on this board but you have to appreciate the difficult situation they are in. If they call a pandemic and nations respond by closing borders and disrupting trade etc and it turns out to be a false alarm, they will be totally excoriated and will have absolutely no credibility - a bad thing if a pandemic does take flight and nations are reluctant to heed their warnings. It’s an imperfect system but it is all we have.
Well put!
Any word on the nurse? The promed article mentions she was suspected of showing symptoms before possible exposure - but is she a confirmed H5N1?
I heard that they determined she was not H5N1.
Scary thought that she would be treating H5N1 patients if she possibly had a different flu… recombining opportunity is not what we should be presenting to the bug right now!
Quartzman, I believe the nurse tested negative. Can’t remember the source at this time…
I don’t have the link right now, but it was negative and she had symptoms before she started treating them (strange but that says something). Try the Indonesia heath workier thread.
One only needs to look at the terrorism warning alert system in the US to understand how complicated this is…over time people came to dismiss it as overreacting, and over utilized…then ignored. Yet if you don’t call it once, or get it wrong and something happens you are discredited and worse. WHO must be tracking thousands of rumors and reports - while worrying about the reports and rumors that are unseen because they are in some remote or war torn place. Either way they only have one chance to get it right or wrong. If they make a mistake either way we all lose - an incredible responsibility. I have no doubt they are doing their best to get it right.
anon 58. I would have sympathy for the WHO except that they went to great efforts to spin and deliberately mislead using data that they knew was incorrect. When given the opportunity, they did not correct the record.
When science is brought to this level…I would not expect too much if I were you.
Weathermen are wrong quite often, yet manage to keep their jobs and credability. Why not think of it in that way. We are amateur weather predictors, keeping them as honest as we can.
AdviceOne
Would also advise anyone to start your preps now, not to wait until the last minute. At least do some basics, rice, beans, masks, water. I started last Fall, still not done. Of course I have been known to procrastinate on rare occasion. [g]
Regardless of the present situation in Indonesia, once the roller coaster starts down that big hill it will be pretty much too late to do any serious prepping. For your own peace of mind, do it!
Heather, nice to see you back in action. Prayer for your Mom..
I admit the politics of international bodies are torturous…they are only as good as the participant nations allow them to be and trying to keep participant nations engaged while maintaining the integrity of the system does not always achieve the desired results. My personal plans change little based on what they (WHO) does…I am most concerned that this will emerge out of areas of the world where governments neither tread or control and media is mute.
Here’s a headline from the Santa Barbara News Press: “Warning issued that bird flu virus may have mutated into highly contagious” “experts think” but experts were not named though. The article goes on to say what we all know about rapid spread, supply lines empty, stay away from people. Mentions a live chat at www.avianflutalk.com. Attributed to Fullerton, CA market wire My pulserate went up, even though I don’t believe it.
It’s junk news from yesterday.
I continue to watch for the “unusual event” in Indonesia, such as a large cluster and watch how it is managed by the Indonesian health department. Indonesia has been ineffective at controlling the H5N1 disease in the bird population. Hopefully this will change but until it does sporadic human cases and family clusters will probably continue to occur. We must remain vigilant for an unusual event that could potentially signal a change in the virus. This last cluster was “unusual” because of its size. It was not managed well, with suspect cases being allowed to discharge themselves from isolation and mix with the community. Though this is probably not a pandemic virus, the management of these cases should send a warning to the world that at the moment Indonesia is unlikely to contain an pandemic virus or act appropriately in an unusual event. For clarification I do not work with NAMRU2 any longer but I do still live and work as a medical doctor in Jakarta. NAMRU2 remains active in influenza surveillance, indeed the hospital involved in this outbreak in Medan was one of their influenza sites and they helped diagnose this “unusual event.” NAMRU2 continues to work with the NIHRD (equivalent) in Indonesia to improve their ability to diagnose H5N1 outbreaks. It is important that this continues. More international assistance should be provided to Indonesia to help it implement effective control measures for H5N1 or at least to work on containment issues it.
Lily. I guess the question would be what characteristics would you like in a surgeon. I think we would agree that ethics would be important.
Jane - there is not warning in the article…just speculation on the cluster and a reference to some experts that think IF it mutates it will change the world. This is an exanple of headlines often having little to do with content.
Andrew Jeremijenko – at 15:05
Brilliant report - thanks! Wonderful to have someone who “still lives and work as a medical doctor in Jakarta!” I’m sure you will have lots of people here anxious to chat with you Andrew.
G.
We do try to keep them honest on these threads. Chances are they are not reading this, but??? Having lived with a true physician for about 49 years, one with heart and soul and ethics, who only thought of the welfare of his patients in every instance, I do agree. There are those, and then there are those who I do not consider true physicians. Perhaps you can’t expect this from Who. I think some do what they can. But like the weather, this virus is not completely predictable.
Andrew,
Thank you for your excellent summary and all the best for your work.
Andrew- Thank you for your post. It is wonderful to have someone posting who is in the area and following this issue.
Andrew - or should I say Dr. Jeremijenko, your interview with Peter Cave in Feb. of this year, on the Failed Indonesian Bird Flu Response, was excellent.
I was translating an article last night from last year, another interview, one by Wimar Witoelar, in Indonesia, with a bird trader, and although the translation was rough (toggle text) and the article long, I got the impression that there remained much ignorance by the Indonesian people about the Bird Flu. This seemed to be as a result of failed communication by the local governments. This surprised me. Did I get the correct impression from this article? G.
The article was at the http:// address of
perspektif.net/indonesian/article.php?article_id=140
Many thanks Andrew.
Tom-I agree that blood testing is less important than clinical signs. A good diagnostician could identify H5N1 and simply confirm with blood testing. What is the differential diagnosis-dengue fever- the clinical course will be different. How many cases do you think were confirmed serologically in 1918? I think we should pay close attention to clusters of sick individuals in any given place-like last month in India. Maybe WHO should list all outbreaks of any disease when it affects a large portion of a community. The disease and it’s clinical course and final outcome could be explained. It would decrease a lot of the speculation and rumors about H5N1.
Andrew Jeremijenko – at 15:05
Thank you for your comments and your commitment. You are right: international assistance is both paramount and an obligation.
I’m new to this site but am intrigued by Dr. Jeremijenko’s comments and hope he continues to post since he is intimately familiar with the situation given his work with the NAMRU2. Dr. — Looking forward to any additional info you can share with us….
O.K. I’ve checked back at Flickr, Friendster, LiveJournal, and MySpace.com. Javajive is willing to help with Bahasa Indonesia translating. What I want to know is this: how do we ensure that he doesn’t get hit with a flood of requests?? In other words, how are the requests for translations sent to volunteers going to be 1) prioritized and 2) coordinated? We need to put our heads together and answer these questions ASAP, please.
I also have one nibble from someone on LiveJournal, to which I have responded in more detail and I am waiting on a reply.
Other than that, no takers yet :-(
Dr. Jeremijenko, thanks for your report, analysis and clarification.
Do you know why no human or cat sequences have been deposited in GenBank from Indonesia? Is this being blocked by Indonesia or someone else?
Any light you could shed on this would be greatly appreciated.
Is there any further news at allout of Indonesia? It seems that since WHO arrived, the news went dead. How are the other 2 family members doing? What about the other 12 that were hospitalized? I hate when we hear NOTHING!
While we are at it- anyone got any word on the 16 that are in quarentine in Romania?
It is important to continue to watch Indonesia and continue to apply international pressure on them to improve the situation. In the interview with Peter Cave I expressed my concern that Indonesia has failed to match the viruses from the human cases with an animal virus nearby. There are many reasons why Indonesia has failed to match viruses, most of them inexcusable. There have now been over 30 cases of human H5N1 and to date this inability to match the human virus to nearby animal virus continues.
It is not difficult to match viruses you simply take samples from animals and the environment around the area of the human case and send them internationally for analysis. At this stage only human samples are sent across and no animal samples or environmental samples. (Only a few animal samples and environmental samples have been sent internationally at a much later date and most not at all related to the human case) It is important that the international commmunity pressure Indonesia to let competent international avian influenza investigators undertake the investigations and match the viruses as they have failed to do so.
Until we can match viruses and prove where the human cases got their infection we are all just guessing at what is happenning. It will be more difficult to know when a change in the human virus has occurred if we do not have the animal viruses to compare it to. I still believe Indonesia to be a threat to the rest of the world because this matching of virus still has not occurred.
Anonymous (at 15.34) I did not read that article you are speaking of but I do think there is a lot of misinformation and misunderstanding and ignorance about the avian flu virus in Indonesia. The country has 240 million people spread across some 6,000 inhabited islands, many with poor levels of education and a decentralised government. It will always be a difficult task but I agree it is an important task.
Monotreme - the cat virus has been sequenced by the CDC and has been entered on the WHO collaborating centre database which is not GenBank. I agree they should enter that virus on to GenBank. I do not have access to the WHO database.
Quiplash
One reply came in from Karina from Livejournal. I’ve got her email. Also I have mamypoko’s email. On top of this I believe there are 2 other possible contacts other wikians have made (NIdaho with one, someone with another).
Dr. Jeremijenko,
Thank-you very much for your response. Very informative!
Quiplash
Should we have a page with translators’ contacts or something? A list of translators for each region and their emails? We could set up contacts in advance for situations like this. Romania, for example, or Turkey. you could cast nets on myspace and livejournnal now for those areas etc.
Thoughts?
Good job, btw Quiplash!
Dr. Jeremijenko,
Thank you!
I just read this from United News International: Le Bugue, France (UPI) May 17, 2006 World Health Organization officials are monitoring avian-influenza deaths in Indonesia, as a number of recent fatalities indicate that a new infection cluster may be emerging in the country that has thus far played host to the greatest indications of widespread viral evolution. As many as eight of the same family, six of whom have died, have been infected with avian influenza, although no local poultry appear to have been affected by the disease, sparking concern that the much-feared human-to-human transmission may be the source of infection.
Local tests performed on the family, who come from northern Sumatra, have shown that five members, including four of those who have died, were infected with the H5N1 strain of avian influenza.
God helps us.
Tinkerbell,
Doesn’t sound like anything we aren’t already aware of.
We have reason to be concerned. But, there have not been any confirmed reports of expansion of this cluster for the last few days. Cross your fingers. We may dodge the bullet this time.
Call me crazy but when I read that it was confirmed H5N1, and read on another site that this particular strain had a 78% fatality rate, and then read here that a couple of sick people walked out of the hospital into an area ripe with tourists and migrant workers, well shucks! That really got my panties in a bunch! Being a mere mortal is tough sometimes.
Yes it is H5N1 - confirmed locally.
78% is correct for this cluster only.
There is a question as to if the walk out actually ocurred or the patient/s left feeling better and returned when their health declined further.
I have been checking this thread for several days now and appreachiate your helpful comments and input. Please allow me to make an OT comment-it’s and emergency . TINkERBELL- if you are the Tinkerbell we all have been looking for for 6 years, please contact your family in WV. Your father is worried sick about you. Much love
The following is from the Indonesian HCW thread, reposted by request by mamyoko.
Translation of http://www.mediaindo.co.id/berita.asp?id=99992 (17 Mei 2006 03:15 WIB)
Infectious diseases The story(or biography) of Birdflu probable patients in North Sumatra is difficult to be traced(or identified)
Author: Kennorton Hutasoit
Median - MIOL: The North Sumatran Health Provincial authorities are facing difficulty in tracing the story (or background or biography) of the bird flu probable (potentially positive) patients that are still being treated or have died.
- According to North Sumatran Health Kadis, Fatni SUlani, they face difficulty obtaining the patients & their families explanation/information to link them to the source of bird flu probable cases in Desa Kubu Simbelang, Kecamatan Tiga Panah, Kabupaten Karo.
- “We’ve done diagnosis to find the background of the bird flu probable cases. However we face difficulty determining the source & spread that lead to the 6 deaths”, says Fatni Sulani in Medan, Tues(16/5).
- Fatni says they’re making efforts to carry out socialisation to find the background/story of the bird flu probable infectious disease in Karo. She hopes the families & patients will give accurate testimonies of their fever/illness. She ordered the medical team handling the cases in the field to examine every patient with fever. “We communicate daily with the midwives & community health centres there, but the results of the fever patients have not reached us as of this moment”, she says.
2 patients recovering
- Fatni says 2 patients with probable bird flu that is still being treated on Tuesday is recovering. Johannes Ginting, still being treated in RSU Haji Adam Malik is walking & fever has subsided. Terang Ginting in RS Elisabeth has negative birdflu, but still needs to wait for his sample results from HongKong.
- Fatni says unfortunately, they’re left with only 3 Tamiflu doses from 600 doses, The procurement of the tamiflu were based on Dept of Health’s estimation/budget, received in Jan 2006.
- “We’re obtaining additional Tamiflu. Eventhough we’ve 3 doses left in Dept of Health, there’re still supplies in RSU Haji Adam Malik & Karo Regional Govn.”, says Fatni.
Dr. Jeremijenko, thank you for posting on Flu Wiki. All of us appreciate the courage of scientists such as yourself who are willing to speak out. Yes, it is inexcusable that those who can act to help prevent this disaster from growing in Indonesia are still not matching viruses. It reminds me of the inexcusable behavior of our own CDC in not releasing sequence data.
I hope you will continue to keep us updated as best you can. Take care.
Thank you ,very much.
Translation by our member
Alaska Denise nephew Omar (Indonesian/American):
Clusters of Bird Flu Cases Increasing
JAKARTA – A case of bird flu in the Kabupaten (District) of Karo, Sumatra Utara is the sixth cluster case in Indonesia. “This is the newest and largest cluster to date,” said Director of Disease Control and Environmental Health, Health Department, I Nyoman Kandun, in Jakarta on Monday the 15th of May.
This cluster case, with eight people infected, demonstrates an increase in cluster size over time. “We must be more vigilant,” said Dr. Tjandra Yoga Aditama SpP(K) DTM&H MARS from the Department of Pulmonology and Respiratory Medicine at FKUI/RS Persahabatan (hospital) in Jakarta, Ahad on the 14th of May.
However, according to Kandun, there has not been any evidence demonstrating a spread of the virus from human to human. To detect such transmission, Dr. Tjandra says, two procedures need to be implemented.
a. Epidemiological surveillance, to detect the possible transmission of the virus from human to human with no history of infection from the same source, a simple example being the infection of approximately thirty Singaporean hospital workers by a SARS patient in 2003, who was known as a superspreader.
b. Virology research, to detect new viruses formed from a merging of bird flu and its human equivalent. If a full merger has not taken place, hybrid viruses which formed internally of H5N1 and externally of H1N1 may be found, for example.
According to Dr. Tjandra, Indonesia is now in the third stage, consisting of limited human transmission, normally between family members. To be considered in the fourth stage, said Dr. Yoga, there must be 25 confirmed cases of the virus.
Continuing, he explained a new discovery was made regarding the receptors for bird flu in human lungs, which are located within the alveoli of the internal lung structure. The location of these receptors directly contributes to the following symptoms: 1. Rapid, widespread damage within the lungs. 2. No discernible human transmission risk, for the deep location of these receptors contributes to the difficulty of disease spreading through the air.
On the other hand, human flu virus receptors it appears are located in the upper respiratory tract, leading to many complaints of sore throats and the easy spread of the virus. “But, when the human flu virus and the bird flu virus have merged, both sets of receptors will be affected. This means that it will easily spread and cause widespread inflammation of the lungs, also known as pneumonia,” said Dr. Tjandra.
http://www.republika.co.id/koran_detail.asp?id=248253&kat_id=13 http://www.flutrackers.com/forum/showthread.php?t=6005&page=2
Dr. Jeremijenko, There has only been one human H5N1 isolate from Indonesia that has been released (HA and NA sequences) and it has a novel HA cleavage site, RESRRKKR instead of the more common RERRRKKR, or the common cleavage site in cases from China RERRRKR (missing a lysine). Recently, Hong Kong released a number of H5N1 bird sequences from Indonesia, in addition to the sequences released in association to an earlier publication.
The RESRRKKR is from the first confirmed case in Indonesia, which as isolated lasted July. Do you know if all (or most) of the human isolates have RESRRKKR?
Do you know why additional human sequences have not been released?
Just to clarify the above post. NONE of the bird sequences have the RESRRKKR cleavage site found in the human isolate, so this difference is useful in determing the source. The human sequence is closley related to several bird sequences and has many Indonesian polymorphisms, but none of the bird isolates have RESRRKKR, nor do ANY H5N1 sequences publicly available at GenBank.
Tramslated human HA sequence
VKMEKIVLLLAIVSLVKSDQICIGYHANNSTEQVDTIMEKNVTVTHAQDILEKTHNGKLC DLDGVKPLILRDCSVAGWLLGNPMCDEFINVPEWSYIVEKANPTNDLCYPGSFNDYEELK HLLSRINHFEKIQIIPKSSWSDHEASSGVSSACPYLGSPSFFRNVVWLIKKNSTYPTIKK SYNNTNQEDLLVLWGIHHPNDAAEQTRLYQNPTTYISIGTSTLNQRLVPKIATRSKVNGQ SGRMEFFWTILKPNDAINFESNGNFIAPEYAYKIVKKGDSAIMKSELEYGNCNTKCQTPM GAINSSMPFHNIHPLTIGECPKYVKSNRLVLATGLRNSPQRESRRKKRGLFGAIAGFIEG GWQGMVDGWYGYHHSNEQGSGYAADKESTQKAIDGVTNKVNSIIDKMNTQFEAVGREFNN LERRIENLNKKMEDGFLDVWTYNAELLVLMENERTLDFHDSNVKNLYDKVRLQLRDNAKE LGNGCFEFYHKCDNECMESIRNGTYNYPQYSEEARLKREEISGVKLESIGTYQILSIYST VASSLALAIMMAGLSLWMCSNGSLQCRICI
Snowy, please thank Omar for his excellent translation—such a pleasure to read after those weird machine translations! I greatly appreciate his help.
This guy just won’t stay put.
17/05/2006 07:58
Liputan6.com, Medan: Jonnes Ginting, the case patient of bird flu that could bolt from the hospital, again was lost from Special Isolation Space the Public Hospital Saint Elizabeth, Medan, North Sumatra. The patient’s loss from the Karo Land from maintenance space to this Tuesday morning (16/5) could make panic of the hospital side. However after the medical team carried out the search, Jonnes was found was engrosseding in drinking coffee after breakfast in the canteen of RSU Saint Elizabeth. The man was 35 years old finally returned to isolation space to undergo the medical handling after being persuaded to be medical by the nurse and the team of this hospital. According to the side of RSU Saint Elizabeth, generally the condition for the Jonnes health began to improve. Because, the temperature of the body and breathless that was suffered by him began to decrease after got tamiflu, antibiotik and antijamur berdosis high [read: the Clear Condition and Jonnes improved]. Resulting from this incident, the hospital side tightened the supervision of the case patient of bird flu that could experience critical this. In the meantime, the suggestion for the patient’s family put on the mask and clothes pengaman as far as this is concerned continued to be violated by the Jonnes family. (ZIZ/Chaerul Dharma and the Arbianto Choke)
http://www.liputan6.com/view/3,122976,1,0,1147867319.html
17/05/2006 14:05
Liputan6.com, Hong Kong: results of the laboratory of the World of the Health Body (WHO) in Hong Kong, just recently decisive five from eight cases of the assumption of bird flu in the Karo Land, North Sumatra positive was infected by the virus avian sub-type influenza H5N1. One of them was experienced by the patient was named Jonnes Ginting that up to now still is undergoing the maintenance in special isolation space of the Public Hospital Saint Elizabeth, Medan, North Sumatra [read: wanted to drink Coffee, Jonnes Ginting Again bolted]. These positive results were known after WHO checked the sample of blood and the saliva of eight bird flu casualties in the Karo Land. Beforehand results of the inspection the laboratory of the Health and the Namru laboratory of the Body of the Department’s Research And Development (Naval Medical Research the Unit) in Jakarta also pointed out five positive patients terjangkit bird flu. This case was cluster sixth and biggest in Indonesia [read: Cluster in the Karo Land that most Big]. As for eight cases of bird flu that happened in the Karo Land for the last ten day claimed six fatalities. While several patients, including Jonnes Ginting and Obviously Borung Ginting still were treated in RSU Saint Elizabeth. However up to now results of the sample inspection of blood and the Clear saliva of Boru are not yet known. (BOG/Coverage 6 SCTV)
So does that mean he further exposed all of the other people in the canteen? I think I would handcuff him to the bed.
WHO confirms six bird flu cases in Indonesia
JAKARTA (Reuters) - The World Health Organisation confirmed six more human cases of bird flu infections in Indonesia on Wednesday, including five members of a family whose case has triggered fears of human-to-human transmission.
“There are six confirmations. One from Surabaya and five from Medan. One from Medan is still alive,” said Sari Setiogi, the WHO’s Indonesia spokeswoman.
Separately, Indonesia’s health ministry said a 12-year-old boy died of bird flu four days ago in Jakarta’s eastern suburb of Bekasi, according to local tests.
Blood samples have been sent to a WHO-affiliated laboratory in Hong Kong for confirmation, ministry spokeswoman Lily Sulistyowati said. Local tests are not considered definitive.
[snip]
“The spread was through risk factors from poultry or other animals. There is no proof of human to human,” Nyoman Kandun, director-general of disease control, told Reuters.
“The world is watching us. We are not being hasty,” he added.
Four of the five family members have died. An eighth member of the family previously reported by the WHO to be part of the cluster of infections merely had a fever and is now not believed to have had bird flu.
[snip]
Asked about the possibility of a change in the virus and whether there had been human-to-human infection in Sumatra, WHO spokeswoman in Geneva Maria Cheng said: “It is too early to draw any conclusions. I have not heard any suggestion that the virus is any different,” referring to the laboratory tests in Hong Kong.
She said local health authorities have told the WHO there is no evidence so far the virus has spread beyond the initial cluster — which it might be expected to do if there were a mutation.
“They do not have cases of people who were connected to the family under observation or suspected of being infected.”
[snip]
But an Indonesian agriculture official who declined to be named told Reuters tests had shed no light on the case.
“There is a big question mark. Blood samples from all kinds of animals from chickens, ducks, geese, birds, pigs, cats and dogs turned out negative so far. Manure has also been checked. The result is negative,” the Jakarta-based official said.
Some reports have suggested chicken manure used as fertiliser might be the link. Infected birds can excrete large amounts of the H5N1 virus and this can be one way it can spread to birds, and people.
The sixth of the cases confirmed on Wednesday was a 38-year-old catering businesswoman from Surabaya who had dealt with live pigs and pork meat before she died last week.
from WSJ today
WHO Damps Fears Over Bird Flu Cluster in Indonesia Offers No Indication Virus Has Mutated By NICHOLAS ZAMISKA May 17, 2006
Health officials played down concerns that a large cluster of human bird-flu cases in Indonesia might indicate that the virus has mutated into a more dangerous form.
…
But the Indonesian cluster, like others before it, fed fears that the virus might have mutated to a form that can spread easily among people.
The delay in defusing speculation about possible rapid human-to-human transmission of bird flu highlights a predicament for the WHO: The United Nations agency is bound to investigate cases but loath to go public with what it discovers before local governments do.
“We’re always waiting for them to take the lead on these things. We provide advice, but after all, this is a sovereign nation, and they represent the authority of the government,” said Dr. Bjorge. He, along with two other WHO officials in Indonesia, declined to release specific information they had about the cluster of cases before the central government had a chance to make it public.
Graham Tallis, a WHO epidemiologist who traveled to the family’s village to investigate the cases, said that while health officials were on alert for cases of fever and there are a lot of health-care workers in the area, “there’s no evidence of spread beyond the family group.”
Reuter is now reporting the April 27 disease onset date for the index case and an April 29 BBQ attended by family members who died and were H5N1 positive, This is clearly H2H.
Regarding Monotreme’s post, I suppose the following quote means Indonesia has yet another H5N1 Case: “Separately, Indonesia’s health ministry said a 12-year-old boy died of bird flu four days ago in Jakarta’s eastern suburb of Bekasi, according to local tests.” I think Indonesia is feeling the pressure for transparency.
Dr. Jeremijenko, let me add my thanks to the many others here. We appreciate you sharing your expertise and time.
So, there are now 2 new additional H5N1 cases (deaths) separate from the Sumatra cluster?
“…In a day of fast-moving events, the WHO also said a caterer from Surabaya city in East Java had died of bird flu, while Indonesia’s health ministry said local tests had confirmed a 12-year-old boy from Jakarta who died four days ago was infected with H5N1. Both cases are separate from the Sumatra case…..”
Indonesian boy dies of bird flu, local test shows Wed 17 May 2006 6:03 AM ET
JAKARTA, May 17 (Reuters) - A 12-year-old Indonesian boy died of bird flu four days ago in Jakarta’s eastern suburb of Bekasi, a health ministry official said on Wednesday, citing the results of local tests….
(Separate case from the Sumatra cluster)
banshee at 9:25:: After the relief of the last couple of days that article that you posted was indeed a “cold shower”. Keep preppin’.
MM, Just keep in mind that these occured in a different part of Indonesia (separate island) and they are individual cases - not clusters. But who knows anymore?
this could be the beginning, we are watching over here, when tshtf over there…as medical maven said, “keep preppin”
For those of you trying to sort out the Indonesian situation, the Sumatra cluster took place in the northern part of the island of Sumatra. The case with the 12 year old boy took place in the Jakarta suburb of Bekasi on the island of Java. Java lies to the southeast of Sumatra. The case of the caterer from Surabaya occured further east on the island of Java. Map link below:
banshee at 9:46: It was precisely the “bubbling”, wide geographic spread of the activity that disconcerted me.
MM, I can’t decide how to read this or if I even should try. Perhaps the 2 new cases are infections from poultry? H5N1 appears to be endemic in most of Indonesia now which would mean that we will most likely see more H5N1 cases resulting from contact with infected poultry. However, the very fact that H5N1 has become so endemic concerns me as well as it gives the virus more opportunity to mutate within humans.
Most distressing to me now is that it was implied that the caterer was infected because of working with pigs/pork. If this becomes endemic in pigs, TSHTF very soon after. Pigs and us have similar lung receptors.
Anonymous, I’ve heard the pig theory booted around as well. However, WHO and the Indonesian authorities seem to be quite puzzled right now as to how people are getting infected. Maybe within the next few days we will get some more solid information as to how the Sumatra infection started as well as the 2 new suspected BF cases.
Dr Jeremijenko, Do you how many of the human sequences have the RESRRKKR cleavage site? Since it is not in any of the many bird sequences from Indonesia, would not the human sequences with RESRRKKR becoming from a source that was not avian?
This thread will soon be closed (length) and a new one started.