Additional H5N1 Denials in Indonesia Raise Pandemic Concerns

Additional H5N1 Denials in Indonesia Raise Pandemic Concerns
Recombinomics Commentary 15:23
November 13, 2008

Siti Fadilah Supari said the 15-year-old girl, who died in hospital in the Central Java city of Semarang on November 7, was not carrying the H5N1 strain.

"Both tests came back negative," she said.

The above denial by the Ministry of Health in Indonesia extends the long list of high questionable statements delivered by Indonesian officials. These denials apply to H5N1 outbreaks in birds and people.

Initial outbreaks of H5N1 in late 2003 were said to be due to Newcastle Disease, but H5N1 sequences from Indonesia from 2003 are now publicly available. Similarly, the first human cluster of H5N1 in Tangerang in 2005 was initially denied, but the H5N1 from the first confirmed case is now the vaccine target for the clade 2.1 H5N1 in circulation in Indonesia.

Moreover, the human to human transmission in that initial cluster is still denied, as are the dozens of similar clusters in Indonesia. The largest official confirmed cluster was in Karo in 2006, but an even larger cluster was in Garut in the following year, although only three of the H5N1 infected patients were confirmed. That cluster followed the typical reporting pattern in Indonesia where the initial case(s) is not tested, subsequent contacts are H5N1 positive, and contacts of these contacts are negative because of decreases in H5N1 RNA levels due to Tamiflu treatment.

In addition to highly suspect comments on H5N1 infected cases, the recent failures to provide timely reports of outbreaks has increased concerns. In 2006 Indonesia filed an OIE report indicating H5N1 was endemic in poultry in Indonesia, which relaxed reporting requirements to 6 month intervals, but Indonesia has not filed an official OIE report since 2006.

Similarly, reporting regulations were disregarded with respect to confirmed human cases earlier this year after multiple H5N1 clusters were discovered. Those clusters followed the typical pattern of misdiagnosing the index cases as lung inflammation, dengue fever, or typhus. These fatal cases were followed by symptoms in relatives which were then subsequently H5N1 lab confirmed, leaving little doubt that the earlier infections in relatives were due to H5N1, yet the ministry of health officials continued to deny that the index cases in the clusters were H5N1 infected.

After the third cluster was reported, Indonesia announced a change in reporting of confirmed cases, which was in clear violation of International Health Regulations. Indonesia announced that instead of notifying WHO 24-48 hours after lab confirmation, they would issue periodic reports every few months, or as long as every 6 months.

Moreover, in addition to denying H5N1 infections and failure to provide timely reports, Indonesia has withheld samples and sequences necessary to monitor the evolution of H5N1 in patients and birds. The last public human H5N1 sequences were from patients diagnosed in early 2007, and recently Indonesia announced that they would no longer allow bird samples to be sent to the WHO regional center in Australia for sequencing.

The above series of actions has significantly reduced the credibility of statements issued by the Ministry of Health. The coup de grace was the statement that the lower number of H5N1 human cases was due to prompt treatment, which lacked logic unless there was a high level of human to human transmission. Prompt treatment of H5N1 patients would not reduce the number of confirmed patients, but would reduce the case fatality rate. However, the case fatality rate in Indonesia has remained close to 80%. Treatment of H5N1 infected patients would only lower the number of reported cases if the treatment led to false negatives, which would reduce the number of reported cases, but not the number of H5N1 infected cases.

The long list of controversial statements and actions by the Ministry of Health has not led to more active investigations by the WHO. They continue to issue situation updates on patients who were infected weeks or months prior to the WHO report, and the true level of H5N1 cases and human to human transmission remains largely unknown to those inside and outside of Indonesia.

The latest case, which was said to be lab confirmed, has now been denied, and the status of the 17 patients hospitalized in Makassar, South Sulawesi remains unclear, as Indonesian actions and statements, coupled with lack of action by WHO, continue to be hazardous to the world's health.