Bird flu news from the 3rd world: Is it that hard to get the facts?

[Skeptic Ginger]

This is from the Infectious Disease Society's daily update. It's a reminder not to believe everything you read or hear in the news, as if we needed reminding. I highlighted some of it just to make it easier to spot the contradictions.

Indonesia
Date: Mon, 15 May 2006 17:08:42 -0400 (EDT)
From: Mary Marshall, <tropical.forestry@btinternet.com>
Source: Crofsblogs, 14 May 2006 [edited]
<http://crofsblogs.typepad.com/h5n1/2006/05/a_summary_of_ta.html#more>

The following report has been cobbled together from a combination of news sources, some local to Sumatra and others international.

A large cluster of H5N1 cases among an extended family in the Indonesian province of North Sumatra, on the island of Sumatra, has health officials around the world concerned. Reports from the location have been incomplete and conflicting, but the following is the best information available as of Sunday evening.

In a village about 175 kilometres south of the provincial capital of Medan, 7 or 8 members of an extended family were hospitalized more than a week ago with suspected bird flu. On 12 May 2006, Pengendalian Breakingprep Penyakit, director general of the North Sumatra Department of Health and Environmental Sanitation, confirmed that at least 5 of the 8 suspected bird flu cases had tested positive for the H5N1 virus in local testing. Samples have been sent to a WHO-affiliated lab in Hong Kong for verification.

Some local news sources stated that the family lived in the same small home, while other sources indicate that they lived close to one another in the same village, but in different homes. In any case, the family was taken to Medan (the provincial capital) for hospitalization at the RSUP (Central Public Hospital) Adam hospital.

The first death to come to the attention of the international community was [a 19 year old man, the index victim], who died Tuesday, 9 May 2006, 11 days after first showing symptoms. His mother, [40 years old], had died on 4 May.

On Wednesday, 4 May, a woman aged 29 died at the hospital at about 5 a.m. local time. Her relationship to the others has not been clearly stated, though there is some indication that she may have been an aunt of the 19 year old man. She was identified by some local sources as living in Kabanjahe, the capital of the Karo Regency (district), and not in the village where the others lived, but the accuracy of this last statement is not known.

A 18 year old man, brother of the index victim, died on 12 May.

A boy, age 8 (some sources said 10), died Saturday, 13 May, at about 2 p.m. local time, at RS Elizabeth hospital, also in Medan. This may be the individual identified by some news sources as a cousin of the index man, a child aged 8. This also may be the source of reports that 8 members of the family were hospitalized, rather than the 7 for whom we have identification.

A baby boy aged 18 months was originally reported as having died on Friday 12 May, but it was later learned that he did not die until Sunday 14 May. This date of death was confirmed Sunday by I Nyoman Kandun, director general of disease control at the health ministry.

On 13 May, local media reported panic in the region (but, if there were panic, it likely was in the Karo district rather than in Medan itself). They also reported that the 2 surviving members of the original family were transferred to RS Elizabeth after they attempted to flee the hospital. The accuracy of these reports of attempted flight have not been verified, but it is known that the 2 survivors (not the toddler) were transferred to RS Elizabeth, where one of them died on 13 May. Other sources reported that the 2 were released from hospital, but hospitalized again after their conditions became worse. This last report seems far more unlikely than that they attempted to flee.

Both local and international media reported that one or more family members originally contracted the disease from contact with contaminated fertilizer. According to local sources, the family often bought manure from 2 unidentified vendors whose poultry had recently been found positive for the H5N1 virus.

On 12 May, in addition to reporting 2 deaths (one of which did not happen), local sources also reported that 12 people remained hospitalized in RSUP Adam with suspected bird flu symptoms. It was not stated if these people were other relatives, friends and neighbors, or just what their exact association with them was.

These sources also reported that, worried by the spread of the disease, the provincial government of North Sumatra ordered the Karo district health service to sterilize the family's home along with an area of 1 kilometre radius surrounding it. This also means culling or vaccinating all poultry in that area.

WHO officials in Indonesia said Sunday that tests of livestock in the village showed positive results for the H5N1 virus and now poultry and swine in the village are being tested. No indication was given if by "livestock" the WHO meant cattle, nor why (if it does mean cattle) these animals were tested before poultry and swine, both of which have stronger indications for infection than do cattle.

This outbreak is the largest familial cluster reported in Indonesia to date. It also may be the largest familial cluster ever reported for the H5N1 virus and has international health officials worried that the disease may be mutating to become more easily transmitted between humans.

H5N1 has been in Indonesia since 2003. The first human infections, however, were only reported in 2005.

There are many issues involved in getting news of this outbreak out of Medan and North Sumatra. First, is the problem that local news sources are all in Indonesian, which not only is a different language, but even has a different character set (alphabet) from English. Second, the accuracy of local news sources is highly questionable. Third, both hospital and government officials may not always be forthcoming with information about victims or the course of the disease.

Readers also should be aware of the following language issues with reports coming out of the North Sumatra area: Karokaro is sometimes transliterated as Karakar or as Karo-karo; Beru is sometimes transliterated as Boru, and is often abbreviated as Br.

And an additional note of confusion:

Indonesia
Date: Mon, 15 May 2006 05:06:20 -0400 (EDT)
From: Andrew Jeremijenko, <Andrew.Jeremijenko@vico.co.id>
Source: The Wall Street Journal, 15 May 2006 [edited]
<http://online.wsj.com/article/SB114760647060852360.html>

It wasn't immediately clear whether the family members had been exposed to infected poultry. Dr Kandun said that the family had at least a few chickens, 2 of which died recently, although birds often die in small numbers for reasons other than avian influenza. He said barbecued pig had been served at the family gathering. [Note this differs from the fertilizer hypothesis.]

WHO has sent an official to the family's village to investigate. "The investigation is still ongoing. It's still too early to say at this point," Sari Setiogi, a spokeswoman in Jakarta for the agency said last night, adding that this was the largest cluster she has seen. "It's a huge number of people that are living in the same place. But the possibility of environmental exposure is also there."

A nurse who attended to some of the patients also came down with an influenza-like illness, although she seems to have shown symptoms prior to treating the patients, according to Dr Kandun. She and others in the family's village are currently being tested for the virus. While there have been no obvious signs of poultry infected with bird flu in the area where the people died, according to Dr Kandun, the virus has been widespread among the country's birds. Many human cases of bird flu have been confirmed in places where there have been no reported infections among poultry. Birds are known to harbor the virus without showing symptoms, and cases of the disease in birds might go undetected.

Information sharing is a funny thing indeed. Humans just love to gossip and the stories change as fast as they change hands. And to compound matters, it seems to me reporters fill in the blanks with anything they feel fits rather than report there are blanks in a story.

 

[Rolfe]

Just an aside.

I spent some time a week ago listening to a bunch of senior (some retired) veterinary epidemiologists loudly proclaiming that H5N1 has been around since some time in the 1950s and it hasn't turned into a global pandemic yet, and some people need to get a sense of proportion. Now I don't know exactly how much they'd had to drink, and I haven't heard a balanced debate between these guys and the group of epidemiologists who are clearly scared as hell, but it was an interesting insight that there is a group of well-informed people who aren't quite ready to book that trip to Mars just yet.

Rolfe.

 

[Dymanic]

I spent some time a week ago listening to a bunch of senior (some retired) veterinary epidemiologists loudly proclaiming that H5N1 has been around since some time in the 1950s and it hasn't turned into a global pandemic yet

It's worth noting that despite the virus having been around that long, there were no reported instances of human infection until 1997, and since then, 208 confirmed cases, over half of which ended in death. Clearly, something changed.

If the virus aquires H2H capability, it will move through human populations much faster than samples move through testing labs, and trying to stay out front of that will inevitably involve a considerable amount of speculation. That's part of the problem. The quarantine/antiviral blanket strategy depends on knowing for sure that you are dealing with a pandemic strain before the virus spreads beyond the boundaries of whatever cordon sanitaire you try to establish.

 

[Skeptic Ginger]

H1N1 has been around at least since the 1918 pandemic too. So what? It the specifics not the category.

I think the actual HPAI H5N1 was first seen ~1996. The first human cases were the 17 cases with about 8 fatalities in Hong Kong in 1997.

 

[SteveGrenard]

It's probably not that hard to get facts once authorities investigate. We would be a lot more worried if we knew for sure one or more of these Indonesian cases absolutely have had NO contact with infected animals.

WHO confirms avian flu case cluster in Indonesia

May 17, 2006 (CIDRAP News) – World Health Organization officials have confirmed five cases of H5N1 avian influenza in an Indonesian family in North Sumatra, plus a fatal case in a woman from East Java, news services reported today.

Additionally, Indonesia's health ministry said local tests revealed the H5N1 strain in a 12-year-old Jakarta boy who died 4 days ago, according to a Reuters report. This case, however, has yet to be confirmed by the WHO.

The North Sumatra case cluster was first reported by Indonesian officials several days ago, sparking concern about the possibility of person-to-person transmission. In today's reports, officials said the situation was still unclear and investigation was continuing. The WHO had not yet published an online update on the situation at this writing.

WHO officials said four of the five infected family members in North Sumatra have died, according to reports. An Agence France-Presse (AFP) story described them as two males, aged 19 and 17, a 29-year-old woman, and an 18-month-old baby. The fifth person, a 25-year-old man, was recovering, according to AFP.

The case in East Java was in a 38-year-old woman who worked as a caterer in Surabaya before her death last week, according to Reuters. She dealt with live pigs and handled pork in her work, the story said.

The five cases in North Sumatra were confirmed by a WHO-accredited laboratory in Hong Kong, Reuters reported. Tests on a sixth family member, a 10-year-old boy who died, are pending, according to AFP. A 37-year-old woman was the first person in the group to fall ill, but she died without any samples being taken.

WHO spokeswoman Maria Cheng in Geneva said it was "too early to draw any conclusions" about whether the virus has acquired the ability to spread among humans, according to Reuters. "I have not heard any suggestion that the virus is any different," she said.

Another WHO spokeswoman, Sari Setiogi, said the agency was carefully investigating the cases, according to AFP. "The current investigation that we have has no evidence of further spread beyond the cluster, so that's quite good news for us because it tells that the virus is not spreading further," she said.

However, Hong Kong virologist Guan Yi told Reuters that the lag reported between symptom onset in the first victim and in the second wave of victims in the extended family was unusual.

"If they were all infected by the same source," Guan said, "their onset time [of illness] would have been closer. . . . They may have infected one another . . . but we have no evidence."

Unofficially, the six new cases—the North Sumatra family and the caterer in East Java—bring Indonesia's case total to 39 and death toll to 30. The WHO had not yet updated its online case count at this writing.




http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/may1706indo.html

 

[Skeptic Ginger]

I wasn't commenting so much here on the bird flu as on the 3rd world news network. I read all sorts of bizarre stories on SARS that were illogical. And there were stories on meteorites causing fires which they do not do. There was one story on a woman giving birth to a frog as if it were a real story.

I started reading news directly from sources originating in some of the less advanced countries, shall we say, when I was looking for SARS information. It was fascinating and quite an eye opener.

Iranian woman 'gives birth to a frog' Clinical biologist says miracle amphibian has human similarities

meteorite starts fire

Some onlookers reportedly collapsed from the shock of the spectacle, and one, a 55-year-old man, was taken to a hospital, where he died 2 days later. In one village, residents say debris set fire to a thatched-roof house, injuring three people inside. So far, only two meteorite pieces have been found.

 

[Bowser]

We can't just walk in there, folks...

It's probably not that hard to get facts once authorities investigate.

Yes, it IS that hard because authorities will not be allowed to investigate, certainly not before it is too late. It has little to do with the "third world news network" and most everything to do with sovereign nations not wanting to cooperate with WHO or anyone else.

http://effectmeasure.blogspot.com/

Friday, May 19, 2006
The problem of Indonesia

What to do about Indonesia? The fourth most populous country in the world, where 26 of 33 of the provinces have reported poultry outbreaks with H5N1, swine may be infected asymptomatically and 40 confirmed cases with 31 deaths, all make Indonesia the current epicenter of bird flu. Its government is struggling and is so far incapable of doing the investigations needed to keep a close eye on the evolution of this fast mutating virus. A well-equipped and technically sophisticated US Navy laboratory (NAMRU2) is operating in country, but a diplomatic spat complicated by the muslim world's backlash against Bush's Iraq war debacle have made it difficult for scientists there to lend a needed hand. The Indonesian government can't get its story straight, is issuing conflicting reports and seems to be intent on muddling through, meaning getting to the next day without everything blowing up in their face. At the same time they are effectively barring international scientists from rolling up their sleeves and finding out what's going on there.

...more...

 

[Skeptic Ginger]

Yes, it IS that hard because authorities will not be allowed to investigate, certainly not before it is too late. It has little to do with the "third world news network" and most everything to do with sovereign nations not wanting to cooperate with WHO or anyone else.

http://effectmeasure.blogspot.com/

Friday, May 19, 2006
The problem of Indonesia

What to do about Indonesia? The fourth most populous country in the world, where 26 of 33 of the provinces have reported poultry outbreaks with H5N1, swine may be infected asymptomatically and 40 confirmed cases with 31 deaths, all make Indonesia the current epicenter of bird flu. Its government is struggling and is so far incapable of doing the investigations needed to keep a close eye on the evolution of this fast mutating virus. A well-equipped and technically sophisticated US Navy laboratory (NAMRU2) is operating in country, but a diplomatic spat complicated by the muslim world's backlash against Bush's Iraq war debacle have made it difficult for scientists there to lend a needed hand. The Indonesian government can't get its story straight, is issuing conflicting reports and seems to be intent on muddling through, meaning getting to the next day without everything blowing up in their face. At the same time they are effectively barring international scientists from rolling up their sleeves and finding out what's going on there.

...more...

Thanks for the blog link, I'll try to read it once in a while.

Just wait on the latest cluster for the facts. Yes the official reports are less than forthcoming. But on the other hand, the public has a hard time with fine details in these reports. The reporters are not educated in the medical field as well. It isn't always a cover up going on.

China has had it's share of cover ups. And anytime there is an economic impact cover ups are frequent. So I'm not saying it isn't done. But in this case, we really need to wait for the science to be done. Remember, there could be billions of prevention dollars for Indonesia if person to person spread is confirmed.

 

[Dymanic]

Thanks for the blog link, I'll try to read it once in a while.

The reveres (not a single person, but several whose positions in the epidemiological field could make things awkward were they to post openly) have also been significant contributors to the science section of FluWiki.

Yes the official reports are less than forthcoming. But on the other hand, the public has a hard time with fine details in these reports. The reporters are not educated in the medical field as well. It isn't always a cover up going on.

I don't disagree with that, but there is a downside to waiting for the science to be done: the science is just too damn slow. Perhaps that's because it is hampered by politics. That happens. We're not going to change that overnight, any more than we are going to change the heavy reliance on "just in time delivery" that is the basis for distribution of goods of all types in modernized countries, and which makes us so vulnerable to the effects of widespread absenteeism. The bottom line is that if this thing makes the break to H2H, it could easily be raging across continents by the time a consensus is even reached as to whether a response should be marshalled.

I'm waiting for the facts on the latest cluster. With interest. But I'm not counting on getting facts in time to do anything much with them, and I'm not waiting to lay in a several-months supply of beans and rice. I did that long ago; before Turkey even.

 

[Ben Best]

It's worth noting that despite the virus having been around that long, there were no reported instances of human infection until 1997, and since then, 208 confirmed cases, over half of which ended in death. Clearly, something changed.

What may have changed is greater attention to what is happening and better diagnostic tools. Many people still die of "unknown causes".

 

[Dymanic]

What may have changed is greater attention to what is happening and better diagnostic tools. Many people still die of "unknown causes".

In addition to the virology and the epidemiology of this "bird flu" business, I'm also interested in the psychology (the politics I don't dabble too much in; they're complicated, dynamic, and frustrating, and I just don't have the time). I'm pretty skeptical myself about a great deal of what I see on the subject, but it seems to me that a willingness to make a stretch like the one you've just made can only be the product of a very strong desire to make this thing go away. If doing that is that important to you, my advice would be to turn away every time you see the subject come up, because that bubble's going to get popped the minute you really start looking into things.

In its highly pathogenic form, avian influenza is hard to miss. When it enters poultry flocks, mortality can approach 100% within 48 hours. When humans in a region affected by such an epizootic event begin falling ill and dying, it's the sort of thing that tends to get attention, especially from those who get paid to pay attention to that sort of thing.

The potential for an influenza pandemic is not a recent media invention. Human deaths due to mysterious respiratory illnesses are something epidemiologists have had an eye out for for a long time, and believe it or not, diagnosing influenza was not beyond the capabilities of the diagnostic tools available even back in the stone ages of the last few decades.

 

[Skeptic Ginger]

What may have changed is greater attention to what is happening and better diagnostic tools. Many people still die of "unknown causes".

No Ben, not in this case. There is more than just reported cases as evidence. At least a few epidemiological studies have been done looking for antibodies in people who were in contact with the infected poultry as well as genetic tracing of the H5N1 and it's related strains.

Of course a case or two were likely missed and maybe even more but it looks like in the countries with the best monitoring, we are seeing most of the cases. And while a few people in China had related antibodies, the Hong Kong cases were the first with the current strain.

Something did occur genetically when a large outbreak occurred in wild birds especially a particular species of geese in the Qinghai Lake region of China as the bird pandemic grew rapidly after that and the genetic strain matched the Qinghai lake strain most closely. interesting in that now it may turn out farming of these wild geese may have played a role. China wasn't very forthcoming on that fact but it has been revealed recently that there was some geese farming in that area with the specific species involved.

 

[a_unique_person]

This is from the Infectious Disease Society's daily update. It's a reminder not to believe everything you read or hear in the news, as if we needed reminding. I highlighted some of it just to make it easier to spot the contradictions.

Indonesia
Date: Mon, 15 May 2006 17:08:42 -0400 (EDT)
From: Mary Marshall, <tropical.forestry@btinternet.com>
Source: Crofsblogs, 14 May 2006 [edited]
<http://crofsblogs.typepad.com/h5n1/2006/05/a_summary_of_ta.html#more>
And an additional note of confusion:

Indonesia
Date: Mon, 15 May 2006 05:06:20 -0400 (EDT)
From: Andrew Jeremijenko, <Andrew.Jeremijenko@vico.co.id>
Source: The Wall Street Journal, 15 May 2006 [edited]
<http://online.wsj.com/article/SB114760647060852360.html>
Information sharing is a funny thing indeed. Humans just love to gossip and the stories change as fast as they change hands. And to compound matters, it seems to me reporters fill in the blanks with anything they feel fits rather than report there are blanks in a story.

Don't forget that Indonesia is a very large, third world nation, spread out across thousands (IIRC) of small islands and several large ones, with no real control of several areas. It is very hard for anyone to know exactly what is going on in that country.

 

[Skeptic Ginger]

Don't forget that Indonesia is a very large, third world nation, spread out across thousands (IIRC) of small islands and several large ones, with no real control of several areas. It is very hard for anyone to know exactly what is going on in that country.

No doubt.

I hope you all know I'm not being critical in this thread. The world is the way it is. I just happen to find it fascinating that I live in such a different world, (where the news gets it wrong as well) than the world one glimpses from these stories.

 

[SteveGrenard]

NYTImes article discussing human to human transmission possibilities:


http://www.nytimes.com/2006/06/04/world/asia/04flu.html?ex=1150084800&en=595ebe1cf527875b&ei=5070&emc=eta1

 

[Dymanic]

Accurately pinning down onset dates is difficult, but it has become increasingly difficult to explain the clusters as anything but human-to-human transmission. The fact that the clusters haven't been any larger than they have suggests that the virus has not yet aquired efficient H2H transmissibility -- but considering what changes the virus may have aquired through mutation (or reassortment/recombination) is not the only approach possible; it is also argued that as the virus becomes more widespread in birds (especially poultry), it is more frequently encountering small pockets of genetically-determined susceptibility in human populations. It's sort of a good news/bad news thing. The good news is that the virus isn't erupting in a pandemic already. The bad news is that little pockets of genetically predisposed humans could provide the virus with the idea environment for becoming better adapted to a wider range of human hosts.

 

[SteveGrenard]

Source: BBC News online, Fri 23 Jun 2006

http://news.bbc.co.uk/1/hi/world/asia-pacific/5110084.stm

The World Health Organisation (WHO) has said it believes limited
human-to-human transmission of H5N1 avian influenza virus did occur
in an Indonesian family in May. But it said that the incident did not
signal a major change in the spread of the disease. The WHO made its
announcement at the end of a 3-day bird flu conference in the
Indonesian capital, Jakarta.

 

[Bowser]

China received a recent black eye in its botched attempts to hide the level of h5n1 within its borders. Here are some items about a letter published in the most recent New England Journal of Medicine and the efforts to block its publication. Someone in China died from h5n1 in 2005 - 2 years before the first case China has admitted to. First up, the letter itself:

http://content.nejm.org/cgi/reprint/354/25/2731.pdf

http://www.cbc.ca/cp/health/060623/x062320.html

http://www.fluwikie2.com/pmwiki.php?n=Forum.TheChinaSyndrome