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Recent Cases Of Bird Flu H5N1 In The Muslim World With Indonesia And Egypt The Most Affected - Islamic And World Perspectives On Bird Flu H5N1

Mixed signals on granite exports to Singapore

Mixed signals are being sent over the issue of granite exports to Singapore, with the environment ministry and the Navy hinting at a possible ban while the Riau Islands provincial administration has guaranteed the exports will continue.

State Minister for the Environment Rachmat Witoelar said Sunday his office was studying the impacts of granite mining and exports on the environment to determine if an export ban, similar to an earlier one slapped on sand, was necessary. 

"We haven't banned the (granite) exports yet but we must limit any exports of natural resources if our environment is being damaged by the mining of these resources," he told The Jakarta Post. 

Rachmat said officials would determine whether granite mining was as harmful for the environment as sand mining, which was found to have completely destroyed several small islands. The government recently banned sand exports to all countries, citing the environmental impact of mining. 

The Navy offered its own opinion Saturday, suggesting granite exports also be banned on environmental considerations. 

"If the impact (on the environment) is similar (to sand mining), we should also impose similar regulations on granite," the commander of the Navy's Western Fleet, Mulyono, was quoted as saying by Antara. 

Granite mining, the Navy said, has caused environmental damage in a number of areas in Riau Islands province, including on Bintan and Karimun islands. 

Another Navy official, Tanjung Pinang Naval Base commander First Marshall Among Margono, said the issue of banning granite exports was now being discussed at several ministries, including the Energy and Mineral Resources Ministry, the State Ministry for the Environment and the Trade Ministry. 

He said the Energy and Mineral Resources Ministry was studying the tolerable limits of granite mining, while the Trade Ministry was calculating the economic losses and benefits of granite exports. 

Riau Islands Governor Ismeth Abdullah, however, guaranteed that despite a number of seizures of ships carrying granite aggregate by the Navy, granite exports would continue. 

"It is true that the Navy has intercepted several barges carrying granite, but they (the barges) were not following proper procedures. We guarantee that export activities will continue in the province as the export of the material is not banned. No more ships will be detained if they follow procedures," he told the Post. 

He said Riau Islands would oppose a ban on granite exports, which would further slash provincial revenue following the central government's ban on sand exports. 

Indonesia has banned sand exports to all countries since Feb. 6. Nearby Singapore, which needs sand for its booming construction industry, was hit hardest by the ban. 

Because of the sudden rise in sand and granite prices, many parties have attempted to smuggle the materials abroad. The Navy says it has detained 18 barges carrying sand, covered by granite, to the city-state. 

Singapore has questioned moves to detain the barges, saying granite exports are legal. 

Death toll at 65 as two more Indonesians die from bird flu 

Indonesian health officials say a 20-year-old woman who tested positive for bird flu has died, making her the country's 64th human victim of the deadly H5N1 virus.
The woman had direct contact with infected chickens and died on Sunday in West Java province, a day after being diagnosed with the H5N1 strain of the virus. 

Two of her neighbours are in hospital with symptoms of the virus.

The woman had the classic symptoms of bird flu, difficulty breathing and a high fever but was also suffering from pneumonia.

Local media have also reported the death of a 9-year-old boy at 4:30 p.m. also on Sunday in West Java, who was referred to Slamet Hospital on the advice of health officials on Sunday morning.

If confirmed he will be the country's 65th human victim of the virus.

Indonesia's first human case of the avian flu appeared in 2005 and since then 84 people have contracted the virus and 65 have died.

Indonesia has the highest human death toll in the world from the virus.

Although the virus does not as yet pose a large-scale threat to humans experts are concerned that should the virus mutate and acquire the ability to pass between humans a worldwide pandemic could result.

Administrators in provincial areas are being urged to follow Jakarta's lead and ban backyard poultry farming following the two deaths, and Health Minister I Nyoman Kandun says the deaths are a reminder that all poultry must be kept away from people and homes.

Kandun says the deep-rooted tradition of people living near their poultry was creating difficulties for the government in controlling the spread of the virus from birds to humans.

Indonesia privatizes bird flu
Thu, 02/08/2007

Dimas Ardian/Getty ImagesIndonesia, the country with the highest number of human bird flu victims, has decided to share samples of its H5N1 virus with drug manufacturer Baxter International instead of the World Health Organization. In return, Indonesia will gain full access to any vaccine Baxter develops, according to the agreement. The move comes as the WHO is striving to extend international sharing arrangements for seasonal flu strains and potential pandemics, so the global health body is very concerned about the deal.

Baxter has made it clear, though, that Indonesia's decision not to share with the WHO has nothing to do with its agreement. So why is Indonesia refusing to collaborate now? Health Minister Siti Fadillah Supari explains:

[Specimens sent to the WHO] have been forwarded to their collaborating centre. There they have been used for various reasons such as vaccine development or research.

Later they sold the discovery to us… This is not fair. We are the ones who got sick, they took the sample through WHO and with WHO consent and they tried to produce it for their own use.”

The WHO fears that everyone will lose out if other countries follow suit. Drugs would likely become more expensive for those countries not party to a private deal with a drug company. Ironically, through its arrangement with Baxter, Indonesia could actually be making its problems worse in the long run. 

Turkey confirms return of bird flu among chickens
09/03/2007

Turkey confirmed an outbreak of bird flu in the southeast of the country on Thursday, a year after the H5N1 strain of the disease killed four children in the region. 

The Agriculture Ministry said in a statement on Thursday 170 chickens had died of bird flu in Bogazkoy village in the province of Batman. The ministry said it believed wild birds had spread the disease. 

Three children with flu-like symptoms from the village were taken into hospital for observation but this was only a precaution, local officials said. 

"We have put under quarantine an area of three square km," Batman Governor Haluk Imga told Reuters. 

"We will cull nearly 1,500 chickens, ducks and turkeys in that area. A 25-man team is carrying out this work." 

Veterinary experts were carrying out tests to determine whether the virus was the deadly H5N1 strain. 

Last year, the World Health Organisation (WHO) confirmed four deaths in Turkey from H5N1 -- all of them children from the town of Dogubayazit near the Iranian border. 

Eight other Turks tested positive for the H5N1 strain but recovered, according to WHO data. More than 160 people worldwide have died of the virus since 2003. 

Scientists fear the H5N1 virus could mutate to a form easily transmitted from human to human. As people would lack immunity, it could then sweep the world, killing millions, they say. 

Victims usually contract bird flu through direct exposure to diseased or dead poultry. 

Experts believe migratory birds originally brought the virus to Turkey and Europe from Asia and Russia, infecting domestic poultry. Turkish authorities culled more than 1.3 million birds during the 2006 outbreaks. 

Bird flu is cited as one of the factors behind a 7 percent drop in Turkish tourism revenues in 2006 from the previous year.


First Human Bird Flu Death In Nigeria Reported
Nigeria - Human Toll From Avian Influenza
Continues In Country And In Egypt
2-8-7

The first human death from avian influenza has been reported in Nigeria, according to the World Health Organization (WHO), and the highly pathogenic Asian strain of bird flu has been found for the first time in the United Kingdom. The H5N1 virus was found in turkeys found dead on a farm in Suffolk, United Kingdom. 

On February 6, the Egyptian Ministry of Health and Population also announced a new human death from H5N1 virus infection. The case was confirmed by the Egyptian Central Public Health Laboratory and by the U.S. Naval Medical Research Unit No.3 (NAMRU-3) in Cairo, Egypt. (See related article.) 

"NAMRU-3 collaborates very closely with the Egyptian government and, as a WHO reference laboratory, conducts testing at the request of the Egyptian Ministry of Health to identify or confirm suspected [avian influenza] cases," said Navy Lieutenant Andrew Stegall, NAMRU-3 administration director, in e-mail correspondence. 

The 17-year-old female from Fayyoum governorate developed symptoms January 25 and initially was treated for seasonal influenza. She was hospitalized February 1 with fever and breathing difficulties, and died the next day. 

Initial investigations into the source of exposure indicate the presence of sick and dead poultry at her home in the days before she became ill. Of 20 cases confirmed to date in Egypt, 12 have been fatal. 

FIRST U.K. OUTBREAK 

In the United Kingdom, the Veterinary Laboratories Agency confirmed February 3 that the H5N1 virus is similar to a January outbreak on a farm in Hungary, where thousands of geese were killed. 

A February 3 report filed by Debby Reynolds, chief veterinary officer with the U.K. Department for Environment, Food and Rural Affairs (DEFRA), with the World Organisation for Animal Health (OIE) in Paris, showed that 2,500 turkeys had died of the viral infection and 4,500 had been destroyed. The outbreak began January 27. 

Poultry are being isolated from wild birds in the area, according to a February 6 DEFRA statement, and all bird gatherings - including shows, markets, fairs and pigeon races - have been banned throughout England, Scotland and Wales until further notice. Investigation continues into the source of the outbreak. 

The U.K. Health Protection Agency advised that the current level of risk to people from H5N1 is "extremely low." 

FIRST HUMAN DEATH IN AFRICA 

The Nigerian government announced February 3 the presence of the H5N1 avian influenza virus in a 22-year-old female from Lagos who died January 16. The victim's mother died January 4 with similar symptoms but no tests could be done because no blood samples were taken. 

The Nigerian fatality brings the total number of human cases around the world since 2003 to 272, with 166 deaths. 

The London-based WHO Collaborating Center for Reference and Research on Influenza confirmed the initial positive test findings of a laboratory in Nigeria. Investigations are under way to identify the source of the Nigerian woman's infection. 

H5N1 virus has been identified in poultry outbreaks in Nigeria and, as in other affected countries, according to WHO, sporadic cases of human infection with avian influenza are not unexpected. 

WHO says it is working with the Nigerian government to carry out intensive surveillance; reports of other suspected cases may occur as people with influenza-like symptoms seek medical advice. 

ACCELERATED VACCINES 

In the meantime, WHO and OIE are working with partners to find ways to improve and promote the development and production of pandemic vaccines. (See related story.) 

One such activity, WHO announced February 1, is to help make pandemic vaccine viruses, which are required to produce pandemic flu vaccines, available to vaccine producers earlier than in the past. 

After analyzing biosafety risks, WHO and OIE agreed that if the pandemic preparedness alert phase reaches level 4 (evidence of increased human-to-human transmission) or above, pandemic flu vaccine viruses that WHO Collaborating Centers have developed can be made available to vaccine manufacturers before all safety tests are complete, including tests in chickens and ferrets. 

WHO uses six phases of pandemic alert to inform the world about the seriousness of a threat and the need for progressively more intense preparedness activities. The WHO director-general designates the phases. 

Each phase recommends activities to be undertaken by WHO, the international community, governments and industry. The world is now in phase three - a new flu virus subtype is causing disease in people but is not yet spreading efficiently and sustainably among them. Phase six reflects efficient and sustained person-to-person transmission. 

The accelerated procedure could reduce the time needed to develop pandemic vaccines by about 14 days. 

Member states wishing to receive such vaccine viruses should make advance arrangements with customs authorities, courier companies, national regulatory agencies and other authorities, WHO advises. 

Indonesia may sell, not give, bird flu virus to scientists
06/02/2007

Indonesia, which has had more human cases of avian flu than any other country, has stopped sending samples of the virus to the World Health Organization, apparently because it is negotiating a contract to sell the samples to an American vaccine company, a WHO official said Tuesday.

The strains of the H5N1 virus circulating in Indonesia are considered crucial to developing up-to-date vaccines and following mutations in the virus. The official, Dr. David Heymann, said the agency was "clearly concerned" about the development and was in talks with Indonesia.

Heymann, the agency's chief of communicable diseases, said he was not blaming the company involved, Baxter Healthcare of Deerfield, Illinois "But now that this has happened," he said, "we have to sit down and figure out how to rectify it."

Indonesia announced Tuesday that it would sign a memorandum of agreement with Baxter today.

A Baxter spokeswoman said the company had not asked Indonesia to stop cooperating with the WHO She added that the agreement under negotiation would not give it exclusive access to Indonesian strains.

The virus has not yet mutated into a strain easily transmitted among humans. But it has infected 81 people in Indonesia, 63 of them fatally. It killed more people in 2006 than in any previous year and is out of control in poultry in Indonesia, Egypt and West Africa, so experts fear it as much as ever.

In addition, Indonesia's decision upsets the pattern for making seasonal flu vaccines — by choosing among hundreds of samples sent in voluntarily from all over the world — and could set a dangerous example for other countries. Indonesia and other poor countries feel slighted by the system — justifiably so, some experts say — because the samples they send in are used to produce vaccines that they often cannot afford.

"Their concern," Heymann said, "is that their strains have been used by several manufacturers to produce vaccines, and that Indonesia should get some compensation. From their point of view, it's understandable."

A spokeswoman for Indonesia's Health Ministry told Reuters Tuesday that the country "cannot share samples for free."

"There should be rules of the game for it," said the spokeswoman, Lily Sulistyowati. "Just imagine, they could research, use and patent the Indonesia strain."

The Financial Times reported the move by Indonesia Tuesday; the country has not released a flu sample since late last year.

Getting affordable flu vaccines has not been a high priority for poor countries, because they are worried about greater threats that can be prevented by vaccines — including measles, polio, rotavirus and other killers of children — and about medicine for AIDS.

But with the threat of a lethal flu looming and with Western companies able to produce enough vaccine each year for less than a quarter of the world, Indonesia is trying to secure an affordable supply for its people.

The Baxter spokeswoman, Deborah Spak, said the company had done nothing to encourage Indonesia to cut off the WHO

"Baxter has nothing to do with this," she said. "Our role is in developing vaccines. We're not involved in ownership decisions."

Some leading flu experts said they believed that Indonesia was acting on its own, not understanding the ramifications.

"This is counterproductive — it will hurt Indonesia more than it hurts other countries," said Dr. Arnold Monto, an epidemiologist at the University of Michigan. "The WHO should be their biggest friend. Indonesia has a virus with a 70 percent case fatality, and we don't know why. If they want to work with the best laboratories in the world, they should make sure that virus samples can get out."

With human cases breaking out in Egypt, Nigeria and elsewhere, new pandemic flu vaccines could be produced from other strains, Monto added. Indonesia's Asian neighbors are the most threatened by its outbreak and may press it to back down, he said.

In the United States, Thomas Skinner, a spokesman for the Centers for Disease Control and Prevention, declined to comment specifically on Indonesia or Baxter, but said his agency "takes this very seriously and supports the notion of the WHO that this type of information should be shared in a timely manner."

Because flu mutates so rapidly, samples are normally gathered from all over the world. For seasonal flus, an expert committee meets each February to try to predict which three are the most likely to be a problem by October, when the Northern Hemisphere's flu season begins.

The strains are usually rendered harmless by laboratories that consult with the WHO, and the genes responsible for the ability of the virus's outer coat to invade cells are spliced to older, well-known strains. Then this "seed virus" is given free to private companies that produce millions of doses.

The arrangement was informal until the WHO started writing rules for it last fall. To assure countries like Indonesia a supply of vaccine, Heymann favors helping them get plants where they can produce it themselves at low cost.

Until recently, Indonesia had been very cooperative about releasing genetic information about H5N1 flu found in animals and humans there, said Henry Niman, a Pittsburgh biochemist who runs a Web site tracking the genetics of flu cases, recombinomics.com.

The release of sequences — not the virus itself, but the pattern of amino acids in its genes, which shows what mutations it has made — is a touchy subject because some scientists try to keep the data secret until they can publish scientific papers.

A spokeswoman for the Indonesian Health Ministry suggested it might return to releasing sequences soon.

It is not uncommon for universities, for example, to release genetic information but require companies wanting to profit from it to pay royalties, Niman said.

New Bird Flu Outbreaks In Pakistan
2-7-7

New Bird Flu Outbreaks In Pakistan - Farm Conditions Contributed 

Hello Jeff - Avian diseases will spread throughout Pakistan and beyond if conditions at farms are not changed. The following depicts a deplorable situation. 

"Dr. Sajjad said workers in poultry farms were unaware of the dangers of bird flu and they lacked proper training to handle sick and dead 
birds, adding that in poultry farms there were no arrangements to keep healthy birds away from the sick ones. He said that vehicles transporting eggs and poultry from poultry farms to markets and shops were highly contaminated with bird saliva and excrements, and that these vehicles were rarely washed. In addition, transportation of birds and eggs in these dirty vehicles was a grave threat of spreading poultry diseases, including bird flu." 

New Bird Flu Outbreaks In Pakistan 
2-7-7 

(AFP) -- After finding the H5N1 bird flu virus in small flocks of chickens and peacocks, Pakistan reports its first two cases in almost a year, said officials. 

Food, Agriculture and Livestock Ministry spokesman, Mohammad Afzal, said all the chickens in a flock of 40 birds had died after the deadly virus was detected in Rawalpindi, near Islamabad. 

"The virus was found in domestic poultry in Rawalpindi. Eighteen birds died and tests confirmed they were infected with H5N1 virus, the rest of the birds were then slaughtered," he told AFP. 

Several major chicken farms are located in the area, however, it is believed to be an an isolated case. 

Afzal said the virus had also been detected in a flock of peacocks in Mansehra in North West Frontier Province. Eighteen birds died and the rest slaughtered. 
Afzal added: "There is no case of human infection." 

The virus has not yet been found in commercial poultry following the latest outbreak and the government had provided farmers with enough vaccine to protect their birds. 
Pakistan produces 4.5 million chickens annually, while peacocks are often kept for decorative purposes and as a good luck charm to bring their owners wealth. 

Bird Flu In Pet Birds In Pakistan Confirmed 
2-6-7 

The presence of bird flu in pet birds has been confirmed in a few areas of Rawalpindi and Mansera 

According to details, 18 pet birds have been killed in the area of Saddar, Rawalpindi, and some in Mansera due to the presence of the H5N1 strain. It has been said that a man in the area of Rawalpindi Saddar, has kept several birds at his house, and that 18 died due to the avian [flu] virus. On the other hand, the Ministry of Food, Agriculture and Livestock [Minfal] has confirmed the cases of bird flu in pet birds underlining that no such cases have occurred from any poultry farms where there are hundreds of hens . 

Meanwhile, since the occurrence of bird flu in February 2006 in Pakistan, Minfal in collaboration with provincial livestock departments and the Pakistan Poultry Association, has continued surveillance for the disease throughout the country. The surveillance included 64 000 samples of blood, tracheal swabs, and tissues from the dead and morbid birds. 

In commercial poultry, vaccination against H5N1 is being carried out at large scale, which has given good results. Since the 3 Jul 2006 (outbreak, no further outbreaks or cases of avian influenza (H5N1) have been reported.) 

H5N1 Bird Flu Found In Pakistan
2-6-7 

Pakistani scientists have found the deadly H5N1 strain of bird flu in a small flock of chickens near Islamabad, almost a year after the virus was found in 2 poultry flocks. 

Mohammad Afzal, Livestock Commissioner at the Ministry of Agriculture, said all the chickens in the flock of about 40 birds at a house in Rawalpindi, a city adjoining Islamabad, had died or been culled. "They tested positive for the H5N1 strain," Afzal told media. "It has been contained and there is no danger of the spread of this virus because there are no poultry farms near this house." 

Pakistan Medical Association Concerned Over Bird Flu Reports 
2-6-7 

Showing grave concern over the reported presence of bird flu in a cottage poultry farm in Rawalpindi, the Pakistan Medical Association (PMA) Karachi Chapter on Tuesday [6 Feb 2007] expressed its fear that the lack of hygiene standards in [the country's] poultry sector might spread the deadly disease in the country. PMA Karachi General Secretary Dr. Qaiser Sajjad told PPI [Pakistan Press International] that according to Livestock Commissioner at the Ministry of Agriculture, Muhammad Afzal, all the chickens in the flock of about 40 birds at a house in Rawalpindi had died or been culled as a result of H5N1. He said that Pakistan's 1st reported cases of H5N1 bird flu were found in chickens in February last year [2006] in the NWFP [North-West Frontier Province], where about 40 000 chickens were culled. 

He regretted that almost the whole poultry framing sector, as well as shops selling chicken, were being run on unhygienic lines and there was no check and balance to impose proper hygienic and precautionary measures to ensure safety of poultry farm and chicken shop workers and consumers, especially housewives who directly touch raw chicken and eggs during cooking. 

Dr. Sajjad said that former City Nazim of Karachi Niamatullah Khan during his tenure had formed an inquiry committee comprising medical experts, poultry associations, chicken sellers bodies and other stakeholders to visit poultry farms as well as chicken selling outlets in the city to prepare a report about precautionary and hygienic methods being adopted by this sector. He said that the committee members extensively visited poultry farms, poultry markets, and chicken shops in various parts of the city and submitted a report to Niamatullah Khan in which they expressed grave concern over the lack of precautionary measures and hygienic standards in the poultry sector. 

Dr. Sajjad said workers in poultry farms were unaware of the dangers of bird flu and they lacked proper training to handle sick and dead birds, adding that in poultry farms there were no arrangements to keep healthy birds away from the sick ones. He said that vehicles transporting eggs and poultry from poultry farms to markets and shops were highly contaminated with bird saliva and excrements, and that these vehicles were rarely washed. In addition, transportation of birds and eggs in these dirty vehicles was a grave threat of spreading poultry diseases, including bird flu. 

Bird flu strikes again in Thailand
01/02/2007

The H5N1 bird flu virus has re-appeared in a third Thai province, the country's third outbreak this year after a six-month lull, the Agriculture Ministry said on Friday.

All fowl in the immediate area around the outbreak in Ang Thong province, 105 km (65 miles) north of Bangkok were being slaughtered after 16 fighting cocks were confirmed to have died of bird flu, they said.

"The lab test has confirmed that the virus found in the province was the deadly H5N1," senior ministry official Pirom Srichan said on the Department of Livestock Web site.

The virus reappeared in Thailand last month, in two provinces in the north and northeast.

Thailand's previous outbreak of the virus in poultry was in July last year, and the last human death in August, the country's 17th since the virus re-emerged in Asia in late 2003.

The World Health Organization says the virus has infected 267 people in 10 countries and killed 164 since 2003. There are fears that millions could die if the virus were to mutate into a form that passed easily from person to person.

Bird Flu Now Widespread In Cats In Indonesia
1-24-7

The situation in Indonesia continues to worsen, now with H5N1 widespread in cats. The news of bird flu in cats (mammals) refocuses attention on the danger that H5N1 will now easily evolve into a human form. 

The situation has arisen because bird flu, despite all attempts to contain it, has become widespread in poultry and birds. Cats allowed to roam outdoors, eat birds and/or poultry and become infected. This new situation in cats should alert people to the need to keep cats indoors or away from birds and raw poultry parts in countries where bird flu is endemic and widespread. 

Deadly H5N1 May Be Brewing In Cats
1-26-7

Bird flu hasn't gone away. The discovery, announced last week, that 

the H5N1 bird flu virus is widespread in cats in locations across Indonesia has refocused attention on the danger that the deadly virus could be mutating into a form that can infect humans far more easily. 

In the 1st survey of its kind, an Indonesian scientist has found that in areas where there have been outbreaks of H5N1 in poultry and humans, one in 5 cats have been infected with the virus and survived. This suggests that as outbreaks continue to flare across Asia and Africa, H5N1 will have vastly more opportunities to adapt to mammals than had been supposed. 

Chairul Anwar Nidom of Airlangga University in Surabaya, Indonesia, told journalists last week that he had taken blood samples from 500 stray cats near poultry markets in 4 areas of Java, including the capital, Jakarta, and one area in Sumatra, all of which have recently had outbreaks of H5N1 in poultry and people. 

Of these cats, 20 per cent carried antibodies to H5N1. This does not mean that they were still carrying the virus, only that they had been infected, probably through eating birds that had H5N1. Many other cats that were infected are likely to have died from the resulting illness, so many more than 20 per cent of the original cat populations may have acquired H5N1. 

This is a much higher rate of infection than has been found in surveys of apparently healthy birds in Asia. "I am quite taken aback by the results," says Nidom, who also found the virus in Indonesian pigs in 2005. He plans further tests of the samples at the University of Tokyo in February 2007. 

Amin Soebandrio, head of medical sciences at the Indonesian ministry for research and technology, confirmed the report. He says that the infection has also been found in dogs and cats on the Indonesian island of Bali, which has also had outbreaks of H5N1. The new findings follow reports that unusually large numbers of dead cats have been found near many outbreaks of H5N1. "Javanese farmers even have a word for the cat disease," says Albert Osterhaus of Erasmus University in Rotterdam, the Netherlands. It was Osterhaus's lab which in 2004 found that cats can catch the H5N1 virus. Like humans, some cats die and some recover. But unlike humans, infected cats shed large amounts of the virus and pass it to each other. 

Infected cats may not directly increase the danger of people catching the virus, as humans seem to catch the current strain only with difficulty even from birds, which they kill, pluck and eat. The main worry, says Osterhaus, is that as the virus replicates in cats, it will further adapt to mammals and acquire the ability to spread more efficiently to people and from person to person, unleashing a human pandemic. 

Nidom's findings are the 1st to indicate what proportion of cats can become infected by H5N1. No cats have been tested in Hong Kong or China. In Bangkok, Thailand all the cats in one household are known to have died of H5N1 in 2004. Tigers and leopards in Thai zoos also died, while last year [2006], 2 cats near an outbreak in poultry and people in Iraq were confirmed to have died of H5N1, as were 3 German cats that ate wild birds. In Austria, cats were infected but remained healthy (New Scientist, 18 Mar 2006, p 6). 

Though Osterhaus says Nidom's figures must be confirmed, he says they aren't surprising, and is even encouraged that they aren't worse. A higher percentage of infected predators than prey makes sense, as each predator eats many prey animals. "At least that percentage shows the virus has not completely adapted to cats, yet," Osterhaus says. If it had, all cats in a stricken area should be infected, as with ordinary flu in humans. 

Osterhaus emphasizes that the cat infections still pose a potential threat. "We know the 1918 pandemic was a bird flu virus that adapted to mammals in some intermediate mammalian host, possibly pigs," he says. "Maybe for H5N1, the intermediate host is cats." If similar percentages of cats are infected at every outbreak location, there must have been many thousands of cat infections since the virus emerged, compared to 267 confirmed cases in humans. Every sick cat is a chance for the virus to adapt, and with renewed outbreaks this year [2007] in birds, people or both in China, Indonesia, Japan, South Korea, Hong Kong, Viet Nam, Thailand, Egypt and Nigeria, it is getting plenty of such chances. 

Killing cats won't solve the problem, Osterhaus warns. Like shooting wild birds, it is unlikely to have much impact and could send infected animals elsewhere. It would also lead to a population explosion of disease-carrying rodents, which the cats normally keep in check. 

"Cats must just be kept from eating sick chickens," Osterhaus says, though this will be a tall order in open-air markets across Asia and Africa, which are typically swarming with hungry cats. In Jakarta this week, officials are slaughtering thousands of banned backyard poultry then handing them back for their owners to eat. Some of the birds could well be infected despite appearing healthy. It is hard to imagine the local cats not getting their share. 

Suspected Bird Flu In 14 Year Old Boy In Azerbaijan
1-24-7

(Reuters) -- Health authorities in Azerbaijan are treating a 14-year-old boy for suspected bird flu, the Health Ministry said on Thu 25 Jan 2007. The boy's sister was one of 5 people who died last year [2006] in an outbreak of H5N1 bird flu in the former Soviet republic between Turkey and Russia, the Ministry said. "It is too early to speak of an exact diagnosis. The boy's blood sample has been sent for analysis to a laboratory in London and is also being analyzed in Baku," said a Health Ministry official who did not want to be named. The boy is being treated in a respiratory illness institute in the capital, Baku. The previous outbreak began last spring [2006]. 

The boy now in hospital is from the southern region of Salyan, which was one of 2 centers of last year's (2006) outbreak. WHO experts traced the infection then to local people plucking migratory birds to use their feathers. It said the outbreak was contained, and since April last year [2006], there have been no confirmed cases in Azerbaijan. 

Girl's death raises Indonesia's H5N1 toll
Jan 25, 2007 

Indonesia’s health ministry announced today that a 6-year-old girl recently died of H5N1 avian influenza, marking the country’s sixth case this year, according to news services. 

The girl, from central Java, died 6 days ago in a Yogyakarta hospital, Ahmad Priyatna, an official with Indonesia’s bird flu information center, told Reuters. He said her neighbors reportedly had dead chickens. 

If the girl’s case is confirmed by the World Health Organization, it will be counted as Indonesia’s 81st case and 63rd death. 

Indonesia has had the most human cases of the several countries with recent avian flu outbreaks. Authorities are conducting a widespread backyard poultry cull in Jakarta to contain the disease. 

Five people in Indonesia’s South Sulawesi province are hospitalized with possible avian flu symptoms, Kahlid Saleh, a physician who heads the avian flu ward at Wahidin Sudirohusodo hospital in Makassar, told Reuters today. The patients, 3 of whom are children, are improving, he said. All are from the same neighborhood, where chicken deaths had been reported. 

In Thailand, 12 children and 1 man from Phichit and Ang Thong provinces are under watch after they became ill following suspicious chicken deaths in their areas, the Bangkok Post reported today. Eight of the children experienced high fevers after a chicken carcass was found in their schoolyard. 

Meanwhile in Nigeria, health officials are investigating two suspected human H5N1 cases, AllAfrica news reported today. A mother and daughter from Lagos, Nigeria’s largest metropolitan area, on the country’s southwest border, died within 2 weeks of eating chicken bought from a live-chicken market during the holidays. The father of the family said that after one of the chickens they bought died mysteriously, the family slaughtered the rest. 

A WHO official told AllAfrica news that he was aware of the case and the WHO was awaiting test results on the woman, her daughter, and a chicken. 

Recombination in the Gharbiya Cluster in Egypt
January 23, 2007

The NA sequences from the Gharbiya cluster were released today at Genbank. NAMRU-3 has released NA sequences from two family members from the Gharbiya cluster (A/Egypt/14724-NAMRU3/2006 and A/Egypt/14725-NAMRU3/2006), as well as from the first case this season (A/Egypt/12374-NAMRU3/2006), who died October 30, 2006. This patient was also from Gharbiya, 12 miles north of the cluster.

The Gharbiya cluster was described in a WHO update, because H5N1 NA sequences from the two fatal cases had the Tamiflu resistance polymorphism, N294S. This polymorphism has been identified in a patient in Vietnam who was initially treated with a maintenance dose of Tamiflu, 75 mg / day. She improved and recovered when the dose was increased to 2 X 75 mg / day. H5N1 from this patient had three readily detected versions of H5N1. One sequence was wild type with regard to NA positions 274 and 294. Three clones had N294S, while six clones had H274Y. H274Y has subsequently been isolated from several patients in Vietnam as well as one patient in Indonesia (from the Karo cluster). Prior to the Gharbiya cluster, N294S had not been isolated from H5N1 patients in the absence of H274Y. However, N294S has been identified in ducks in Zheijang and Hong Kong, raising the possibility that N294S is present in birds in Egypt, and was acquired via recombination that placed this polymorphism of an Egyptian Qinghai genetic background.

The NA sequences from the Gharbiya cluster provide additional evidence for acquisition of polymorphisms via recombination. Recently the HA sequences from the cluster were released. The HA sequences had the M230I polymorphism previous identified in the earlier sequence from Gharbiya. However, both cluster sequences also had V223I, a receptor binding change that had previously been identifies in a Qinghai sequence from a bar-headed goose in Mongolia, as well as several geese sequences from Shantou.

The NA sequences have additional polymorphisms not found in the earlier sequence from Gharbiya. In addition to N294S, the sequences have M29I in the NA sequences. This polymorphism is also present in the same Shantou geese that have HA V223I.

The presence of two polymorphism in two genes that are shared by a common source provide additional evidence for the acquisition of polymorphisms via recombination. The NA sequences are clearly Qinghai sequences, but have a number of additional polymorphisms that are closely linked to the Egyptian isolates from this season and last season, including C150A, C236A, A703G, G743A, T1088C, and G1281A. Overlaid onto this genetic background are several newly acquired changes, including the non-synonymous changes that create N294S as well as M29I. 

The presence of NA M29I and HA V223I in both Gharbiya cluster members as well as the geese from Shantou indicates theses acquisitions are far from random.

Suspect Qinghai H5N1 Cluster in Lagos Nigeria
January 24, 2007

A mother and daughter, who recently died in mysterious circumstances in Lagos, have been suspected to have died of the deadly bird flu disease, thus, giving rise to speculations of a possible human-to-human infection of the disease in the country. 

The two were said to have died within two weeks after they allegedly ate a chicken the mother bought for the family during the Christmas and New Year celebrations at a popular chicken market along Ikorodu Road, Lagos.

While the mother died on the January 4, the daughter also lost her life January 17.

The above comments describe a suspect cluster in Lagos, Nigeria. Such a cluster is not unexpected. Last season the H5N1 Qinghai strain migrated into the Middle East and Africa, resulting in human cases in Turkey, Iraq, Azerbaijan, Egypt and Djibouti. Surprisingly, there were no reported human cases in western Africa, although H5N1 in birds was reported in Nigeria, Niger, Cameroon, Ivory Coast, and Burkino Faso. The largest number of poultry outbreaks was in Nigeria. 

Sequence analysis indicated there were multiple independent introductions into Nigeria, including geographically close farms in Lagos. Many of the sequences in Nigeria are closely related to the sequences in Egypt.

Recently Egypt has had outbreaks in poultry and people, including a three member cluster in Gharbiya, The sequences from Gharbiya have a Tamiflu resistance marker, N294S, which likely was present in bird H5N1 since the samples from the cluster were collected two days after the start of Tamiflu treatment, and the sequences had no evidence of a wild type sequence. Additional sequencing of earlier samples should resolve the role of Tamiflu in the generation of N294S in the sequences from two of the cluster members. In addition to the Tamiflu resistance, the cluster also had an altered receptor binding domain, V223I, which may have contributed to the largest cluster reported to date in Egypt.

The suspect cluster in Nigeria is cause for concern, because of the linkage to Egypt as well as the large number of poultry outbreaks last season and this season. It is also likely that H5N1 is present in countries neighboring Nigeria.

Indonesian woman dies of bird flu, death toll reaches to 62 
21/01/2007

The Indonesian health ministry confirmed on Saturday a 19-year old Indonesian woman who died on Friday was positively infected by avian influenza, putting the total death to 62 out of 82 cases. 

"The test resulted today that she is positive of bird flu," head of laboratory at the health ministry Erna Tresnaningsih told Xinhua. 

The woman from Garut regency of West Java province had been treated in a hospital in the regency since Jan. 16, the head of laboratory said. 

"She died on Friday morning," said Joko Sugiyono, an official of anti-bird flu center of the ministry, told Xinhua. 

The woman has historical contact with fowls as many chickens and ducks around her house died from Jan. 8 to 17, said Sugiyono. 

Another official of the center Muhammad Nadirin said that dozens of fowls near the woman's house had been positively infected by the H5N1. 

"Over 50 fowls near her house were positive of bird flu, based on rapid tests," he told Xinhua. 

The number of bird flu cases in the country has increased recently after months of absence of new cases. 

Four people had died in four days at the beginning of this month, according to the ministry. 

The Indonesian health authorities have imposed a firm policy separating fowls from human and surveillance on the viruses. 

The authorities have forbidden raising fowls in residential areas. The provinces of Banten, Jakarta and West Java have been prioritized of the implementation of the decision as most of the victims are from the territory. 

Over 32 million families in Indonesia's vast archipelago have raising chickens on back yard, Indonesian Agriculture Minister Anton Apriantono has said. 

An 18-year old man infected by the disease and whose mother has died of the virus is still treated in a designed-bird flu hospital in East Jakarta. 

Indonesia has become an international concern since last May when seven people with blood-link were killed by the disease in Karo district in the country's North Sumatra province. 

The country has become one of the front lines in fighting against the H5N1 virus. 

Experts have warned international community of the risks of the disease should Indonesia fail to prevent the highly pathogenic H5N1 virus from spreading. 

Millions of people can be killed if the highly pathogenic H5N1 mutate into a certain level, which can make it transmittable among humans. 

The huge territory, back yard centered farming and relatively lacking of budget have hampered the authorities in the country in fighting against avian influenza. 

Another Egyptian Dies Of Bird Flu
1-20-7

An Egyptian woman died from bird flu overnight after six days in hospital, the state news agency MENA said. 

The virus has now killed 11 people in Egypt, which has the largest cluster of human bird flu cases outside Asia. Eight other people who tested positive have recovered since the virus first surfaced in Egyptian poultry in February. 

Warda Eid Ahmed, 27, from Beni Suef province, south of Cairo, was transferred to hospital in the capital on Jan. 13 suffering from pneumonia. 

A Health Ministry spokesman said earlier in the week she had raised hens in her house. The ministry has dispatched a team to take samples from the rest of her family, he said. 

MENA quoted Health Ministry spokesman Abdel Rahim Shahin on Friday as saying said she was the 11th person in Egypt to die from bird flu out of 19 human cases. 

Three people from one family, including a 15-year-old girl, died of the virus in December, raising fears about the possibility of human- to-human transmission. 

Bird flu has killed at least 161 people worldwide since 2003, according to the most recent World Health Organisation figures. 

H5N1 Confirmed in Egypt
January 17, 2007

A 27-year-old Egyptian woman tested positive for the bird flu virus, the official Middle East News Agency (MENA) quoted a Health Ministry official as saying on Wednesday. 

The woman was identified as Warda Eidh Ahmed, the agency reported. She has been hospitalised since Jan. 13. 

The above report describes the first confirmed case in Egypt in 2007. Earlier this season there were four cases in Gharbiya. Three of these cases were from the same extended family, and the HA sequence from two were recently released.

These two cases, like the October case, had M230I, a change adjacent to the receptor binding domain, that is found in all three human flu strains (H1N1, H3N2, and influenza B) and it creastes an exact match between H5N1 and influenza B at positions 226-230 (QSGRI).

Last season, the first confirmed human case in Egypt was not reported until mid-March. This season human cases have been reported much earlier, and all have died.

Several human cases involving the Qinghai strain of H5N1 were reported in the region last season (Turkey, Iraq, Azerbaijan, Egypt, Djibouti). The Egyptian cases are the first human cases reported this season, and the above cases suggest more will be reported in the near term.

The Gharbiya cluster included an additional change in the receptor binding domain, V223I, and such changes can affect transmission as well as the clinical course. The 100% case fatality rate, which includes a failure to respond to Tamiflu treatment, remains a cause for concern.

Spread Of Bird Flu Around The World
1-12-7

The World Health Organisation (WHO) confirmed on Thursday the death of an Indonesian teenager from bird flu. 

China said on Wednesday that a farmer from the eastern province of Anhui had contracted H5N1, the country's first human case in months. As in other human bird flu cases in China there was no reported poultry outbreak in the area, raising questions as to how he contracted the virus. The outbreak of highly pathogenic H5N1 avian influenza began in Asia in 2003 and spread rapidly in early 2006. 

Following are some facts about the H5N1 avian flu virus and its spread around the globe. 

* Since the virus re-emerged in Asia in 2003, outbreaks have been confirmed in around 50 countries and territories, according to data from the World Organisation for Animal Health (OIE). 

* Since the beginning of January 2006, more than 30 countries have reported outbreaks, in most cases involving wild birds such as swans. 

* The virus has killed 158 people since 2003, according to WHO. Countries with confirmed human deaths are: Azerbaijan, Cambodia, China, Egypt, Indonesia, Iraq, Thailand, Turkey and Vietnam. 

* In total, the virus is known to have infected 264 people since 2003, according to WHO. Many of those who have died are children and young adults. 

* Vietnam and Indonesia have the highest number of cases, accounting for 100 of the total deaths. 

* The H5N1 virus is not new to science and was responsible for an outbreak of highly pathogenic avian influenza in Scotland in 1959. Britain confirmed a new case in Scotland on April 6. 

* H5N1 is not the only bird flu virus. There are numerous strains. For example, an outbreak in 2003 of the H7N7 bird flu virus in the Netherlands led to the destruction of more than 30 million birds, around a third of the country's poultry stock. About 2.7 million were destroyed in Belgium, and around 400,000 in Germany. In the Netherlands, 89 people were infected with the H7N7 virus, of whom one (a veterinarian) died. 

* The H5N1 virus made the first known jump into humans in Hong Kong in 1997, infecting 18 people and killing six of them. The government ordered the immediate culling of the territory's entire poultry flock, ending the outbreak. 

* Symptoms of bird flu in humans have ranged from typical influenza-like symptoms, such as fever, cough, sore throat and muscle aches, to eye inflammations (conjunctivitis), pneumonia, acute respiratory distress, viral pneumonia, and other severe and life-threatening complications. (Sources: OIE, WHO, Centers for Disease Control and Prevention)

Bird flu flares anew in Asia, Indonesian boy dies
Wed Jan 10, 2007 

Bird flu has infected a farmer in China's first human case in months, killed an Indonesian teenager and spread deeper in Vietnam in a flare-up of infections mirroring past winters.

A second Indonesian bird flu victim, a 37-year-old woman from Banten Province on Java island, was in hospital on Wednesday, the World Health Organization (WHO) said.

Most human victims of bird flu have contracted the virus from infected birds, usually chickens, ducks or geese and there is usually a surge in cases during cooler months when the virus seems to thrive. 

The 37-year-old Chinese man from the eastern province of Anhui kept backyard birds, but as in other human bird flu cases in China there was no reported poultry outbreak in the area, raising questions as to how he contracted the virus.

The man developed symptoms of fever and pneumonia early last month and was discharged from hospital on Saturday, the state-run Health News said.

"In China, the challenge is now to identify where this virus is hiding and how it is circulating," Henk Bekedam, the WHO's China representative, told Reuters.

China has reported 22 human cases, including 14 deaths, since 2003 and, with the world's largest poultry population and millions of backyard birds roaming free, it is seen as a center in the fight against the virus.

Bekedam said that as vaccination rates for birds improve in China, detecting avian influenza becomes harder and harder, offering a possible explanation for why there was no reported outbreak where the farmer lived.

BOY DIES

Indonesia has the highest human death toll from bird flu of any nation, and on Wednesday that number grew to 58 when a boy, from Tangerang near Jakarta, died, said the head of the Indonesian health ministry's bird flu center Runizar Ruesin.

The boy was admitted to hospital in the capital last week and deaths among poultry in his neighborhood had recently been reported, the WHO said in a statement posted on its Web site (http://www.who.int). 

Muhammad Nadirin, another official at the country's bird flu center, said hospital staff had to take extra care washing the boy's corpse because of concerns the virus might infect them.

"He was washed using special protection methods to prevent contagion," but added he didn't know if it could be transmitted from human-to-human this way.

The H5N1 virus mostly affects birds, but it has infected 263 people in 10 countries since 2003, killing 157 of them.

Scientists fear the virus could mutate and spread rapidly between people, triggering a pandemic that could sweep the globe in weeks and possibly kill millions.

An adviser to the White House said on Monday the number of people that could die in a flu pandemic that matches the 1918-19 outbreak will be "very scary" and far higher than the 62 million deaths forecast by a recent study by Harvard University.

The 1918-19 "Spanish influenza" pandemic killed anywhere from 20 million to 100 million people.

In Vietnam, bird flu has been confirmed in a fourth Vietnamese province after tests on 70 ducks showed they had died from the H5N1 virus, a government report said on Wednesday.

The results of tests on ducks found dead at the weekend prompted health workers to slaughter around 1,800 more ducks in two communes of Kien Giang province in the southern Mekong Delta, the Animal Health Department report said. 

The virus that first struck the delta region in late 2003 re-emerged last month. Vietnam has had no human H5N1 cases since November 2005. 

75th Case Of Human Bird Flu Case Reported In Indonesia
January 7, 2007

Indonesian health officials on Sunday confirmed its first case of human bird flu affliction this year and its 75th overall, as a teenager is undergoing treatment at a local hospital. 

Nyoman Kandun, an Indonesian health official said, "A 14-year-old patient, still under treatment at the Persahabatan hospital, has been confirmed as being positively infected by the bird flu." 

Kandun said the boy's condition is serious but declined to provide more details. "He is the 75th case of confirmed infection, 57 of whom died," he said said. 

But he said the government's strategy of vaccinating poultry and increasing public awareness on the problem is paying off and that the government was aiming at zero case of human bird flu this year.

Since November 28, Indonesia has not recorded any case of human bird flu. The H5N1 virus has killed more than 150 people worldwide since late 2003, and triggered the mass slaughter of tens of millions of poultry. There are fears it could mutate into a form that could cause a human flu pandemic.

Bird flu kills second Egyptian in two days
27/12/2006

A deadly strain of bird flu has killed an Egyptian girl, the second such death in two days and one that brought the number of deaths in the country this year to nine.

The ministry of health said the 15-year-old girl was admitted to a Cairo hospital on Dec 20 and diagnosed as having the H5N1 variant of the virus three days later.

She died on Christmas Day, the day after Intisar Fareed, 30, who was believed to be her sister, died.

Hassan el-Bushra, a spokesman for the Cairo branch of the World Health Organisation, said Miss Fareed and three members of her family — a sister, 15, a brother, 26, and a cousin, 30 — had tested positive for H5N1.

They lived about 50 miles north of Cairo in Zifta, in Gharbiya province, with 30 other family members, raising ducks.

The brother and sister became infected after slaughtering the flock after three ducks had died of the virus.

The discovery of avian flu in the Middle East has led to the widespread culling of birds.

Eighteen people have been reported to have contracted avian flu since it was detected in Egypt in February.

Egypt lies on a migratory route for wild birds.

The virus has spread to at least 19 of the country's 26 provinces.

The deadly strain of the disease is also known to be present in Iran, Iraq, Israel, Gaza and the West Bank.

The H5N1 strain has hit at least 45 countries and killed more than 150 people but there has yet to be any human cases in western Europe.

Indonesia is the worst-hit country, with about 60 human deaths from less than a recorded 100 cases.

In April, a swan was found to have died from the H5N1 strain of the disease in Cellardyke, Fife.

Egyptian woman dies of bird flu 
25/12/2006 

An Egyptian woman died of bird flu on Sunday, hours after tests confirmed she and two other members of her extended family had been suffering from the highly pathogenic virus, a World Health Organisation official said.

The WHO regional adviser for communicable diseases surveillance, Hassan Al Bushra, said the 30-year-old woman had been in hospital since December 17, but doctors had not immediately suspected bird flu as she denied having had contact with poultry.

The woman was part of an extended family of 33 living in a single house in a village about 80 km north of Cairo, and was the third family member diagnosed with bird flu in 24 hours.

Earlier on Sunday, Al Bushra confirmed that two siblings from the same house, a brother, 26, and sister, 15, had the virus. 

Al Bushra said the family raised ducks in their home, and the brother and sister had slaughtered the flock after a number of ducks had become sick and died.

When officials realised the woman was part of the same family, they tested her for bird flu and confirmed that she was infected with H5N1, and she was moved to a Cairo hospital, but died shortly thereafter.

The two siblings are in hospital in Cairo and have been treated. Her death brings the number of total human deaths from H5N1 in Egypt to eight, and the number of human cases to 18 since the virus first surfaced in Egyptian poultry in February.

Two More`H5N1 Fatalities in Suburban Jakarta
November 13, 2006

The death of casualties was named ES (35) from Tangerang, Banten and A (2,5) from Karawang, West Java, fulfilled the number of bird flu casualties in the homeland to 74 people.

The head of the Centre of Department of Health Communication of the Public of the Bird Flu Command Post, Lily S Sulistyowati, told how this incident started from the citizen's ES of Taman Adiyaksa, Tangerang, from felt was sick (onset) on November 7 2006.

On November 8 2006, ES that various female gender underwent the inspection in RS Paramita Tangerang.Because of not pointing out the improvement, on November 10 2006 ICE was reconciled to RS Honoris, Tangerang.

The same day ES was at once reconciled to RS the Sulianti Suroso Infection (RSPI SS).

The above translation indicates both recently confirmed bird flu H5N1 in suburban Jakarta have died. Most of the human cases in Indonesia have been from western Java and most have died. H5N1 isolated from these patients has a novel cleavage site that does not match the vast majority of H5N1 birds isolates. Additional birds samples sent to Australia fro sequencing have failed to identify the source of the human infections in Jakarta.

Although the isolates have picked up sequences from the Qinghai strain as well as additional polymorphisms from China and southeast Asia, the local reservoir of human H5N1 has not been identified. Although there have been 74 confirmed cases, the number of matches with H5N1 from poultry in the area of the victims remains at zero.

Wild bird surveillance remains poor worldwide. Only one Qinghai isolate has been reported for eastern China, although Qinghai sequences are readily detected in the H5N1 isolates throughout Asia.

H5N1 continues to evolve and the source of human infections in Indonesia remains unlikely to be directly linked to poultry.

Egypt Reports New Bird Flu Infection In Fowl
Nov 11, 2006

A new infection of the deadly H5N1 strain of the bird flu virus among domestic fowls has been discovered in Egypt, the official news agency MENA reported Saturday.

The Health Ministry said that new infection was discovered in Luxor, some 680 km south of Cairo. Tests on domestic birds at the city's Najaa al-Abayda Lab turned up positive for the H5N1 virus, said the ministry's spokesman Abdel-Rahman Shahin.

The area has been quarantined and the birds were being culled, he said.

On Oct 30, an Egyptian woman died of bird flu virus and became the country's seventh fatal human case of the disease.

Egypt reported the first human bird flu case March 18. Since then, it has detected 14 human cases with the last case reported on May 18. Of the 14, six died while the rest recovered.

WHO confirms 3 H5N1 cases in Indonesia
Oct 16, 2006 

The World Health Organization (WHO) today confirmed three fatal cases of H5N1 avian influenza in Indonesia, involving two women from Java and a boy from South Jakarta, bringing Indonesia's toll to 72 cases with 55 deaths. 

The first case involved a 67-year-old woman whose infection was reported by the Indonesian health ministry on Oct 11. The WHO said she became ill on Oct 3, was hospitalized Oct 7, and died Oct 15. Her illness was complicated by a chronic condition, the agency said. 

The second case involved an 11-year-old boy from South Jakarta who got sick on Oct 2, was hospitalized Oct 7, and died a week later. The WHO said the boy had been exposed to dead chickens in his neighborhood. 

The third case was in a 27-year-old woman from Central Java province who became ill on Oct 8, was hospitalized Oct 12, and died the next day. The WHO said the source of her exposure is under investigation. 

The Jakarta Post reported on Oct 12 that doctors who treated the 67-year-old woman suspected she also had encephalitis. Hadi Jusuf, a doctor at Hasan Sadikin hospital in Bandung, where the woman had been hospitalized, said hospital neurologists who examined the woman concluded that she had a brain inflammation caused by a virus. 

Hadi told the Post that the woman was unconscious when admitted to the hospital but that doctors could find no evidence that her loss of consciousness was related to acute respiratory distress or pneumonia, as was true of other avian flu patients treated at the hospital. 

The woman’s cerebrospinal fluid was tested repeatedly after an initial result was negative, Hadi said. He said he had not received results from the health ministry’s lab. If the tests are positive, the woman would be Indonesia’s first avian flu patient to have brain inflammation caused by the infection, Hadi told the Post. 

Neurologic complications of H5N1 infection have been reported before, though rarely. A Vietnamese boy who died of encephalitis in 2004 was later found to have had H5N1 infection, according to a research report published last year. Encephalitis is also known to be a rare complication of ordinary influenza. 

The sole survivor of the avian flu case cluster in North Sumatra last May, Jones Ginting, had brain abscesses after he was hospitalized in May. An Associated Press article, published after he was released from the hospital, said that after he experienced a stiff neck and headaches, tests showed multiple brain abscesses caused by parasites. 

With the three newest avian influenza cases, Indonesia’s case-fatality rate is 76%, which is second only to that of Cambodia, where all six avian influenza patients died. 

The latest cases bring the WHO's global avian flu count to 256 cases with 151 deaths, for a case-fatality rate of 59%. 

Indonesian Woman Dies Of Bird Flu
10-17-6

JAKARTA (Reuters) - A 67-year-old Indonesian woman died of bird flu after being treated at a hospital for more than a week, marking the country's 54th death from the virus, an official at the health ministry said on Monday. 

"The virus in her was highly pathogenic, very vicious. She is the 54th casualty out of 71 cases," said Runizar Ruesin, the head of the health ministry's bird flu information centre. 

The woman from the West Java city of Bandung died on Sunday night, the official said. 

Hadi Yusuf, the doctor who treated her, told Reuters the disease also affected the woman's kidneys. 

Tests last week found she had the H5N1 virus. 

Indonesia has become one of the frontlines in the battle against the disease. No country has suffered from more deaths than this huge Asian country of 17,000 islands where millions of chickens roam backyards freely. 

Despite the rise in the human death toll, the Indonesian government has resisted mass culling of birds, citing the expense and impracticality in a sprawling, populous country where many people are still unperturbed by the bird flu threat. 

Diseases such as malaria, dengue fever and tuberculosis kill thousands of Indonesians annually. 

Indonesian woman in hospital with suspected bird flu
October 11, 2006

A 67-year-old Indonesian woman was seriously ill in hospital Wednesday with suspected bird flu, authorities said.

The woman had contact with chickens before falling sick, but tests on whether she had the H5N1 virus were not yet conclusive, said Runizar Roesin from the national bird flu information center.

"We will not declare it as a positive case until we are 100 percent sure," he said.

Aside from bird flu symptoms such as high fever and breathing difficulties, the woman has also been diagnosed with encephalitis, said Dr. Hadi Yusuf, heading the team treating the patient at the Hasan Sadikin hospital in Bandung, West Java province.

Yusuf said the woman was seriously ill and was breathing through a respirator.

The H5N1 strain of bird flu has killed at least 148 people worldwide since it re-emerged in Asia three years ago, almost one-third of them in Indonesia — the worst affected country — according to the World Health Organization.

Indonesia has been criticized for failing to aggressively deal with the virus in poultry stocks, either by mass slaughters or vaccination. It has said it lacks the resources to compensate farmers for slaughtered birds.

JAKARTA, Indonesia A 67-year-old Indonesian woman was seriously ill in hospital Wednesday with suspected bird flu, authorities said.

The woman had contact with chickens before falling sick, but tests on whether she had the H5N1 virus were not yet conclusive, said Runizar Roesin from the national bird flu information center.

"We will not declare it as a positive case until we are 100 percent sure," he said.

Aside from bird flu symptoms such as high fever and breathing difficulties, the woman has also been diagnosed with encephalitis, said Dr. Hadi Yusuf, heading the team treating the patient at the Hasan Sadikin hospital in Bandung, West Java province.

Yusuf said the woman was seriously ill and was breathing through a respirator.

The H5N1 strain of bird flu has killed at least 148 people worldwide since it re-emerged in Asia three years ago, almost one-third of them in Indonesia — the worst affected country — according to the World Health Organization.

Indonesia has been criticized for failing to aggressively deal with the virus in poultry stocks, either by mass slaughters or vaccination. It has said it lacks the resources to compensate farmers for slaughtered birds.

Report raises suspicion of Bird Flu virus in Iran

A newspaper published in Baku, Azerbaijan has reported that about 2,000 dead birds have been found in a water reservoir in Iran near the Armenian border. 
According to “Olaylar” (and republished on www.day.az), analyses taken from the carcasses has been sent to laboratories in Tehran and in Italy to determine whether the fowl was infected by Avian Influenza (Bird Flu). 

Bird migration raises concern about Avian Influenza 

The specific reservoir was not named in the article. There are two reservoirs on Iranian territory along the Arax River – the Arax-Hydro Unit in Nakichevan and the Horadiz, which borders Nagorno Karabakh. (Iran and Armenia share borders with the Arax.) 

Health officials in Yerevan contacted by ArmeniaNow said they had not heard about any such discovery. 

“I have talked to my Iranian colleague, and he doesn’t have any information, either,” said Grisha Baghyan, head of the State Veterinary Inspection Department of the Ministry of Agriculture. 

Edward Stepanyan, deputy director of the same department told ArmeniaNow that the border with Iran is carefully monitored by Russian soldiers who are on alert for any suspicion of potential health hazards, particularly Bird Flu, and that no information has come from them. 

Stepanyan says that, even if the report is true, Armenia has taken all measures – including stocking up on anti-virus vaccines – to resist any outbreak of the virus. 

Over the summer, various international agencies, including World Bank, USAID, European Commission and World Food Programme, have provided training, equipment and conducted public awareness campaigns in Armenia. 

In January, incidents of Bird Flu were reported in Azerbaijan, Georgia, Iran, and Turkey, near the border with Armenia. While neighbors had outbreaks, Armenian officials assured that no cases of the virus were found here. 

Stepanyan said that, due to recent cooperation with international agencies and based on experiences of other countries, Armenia is “even more prepared than we were last year” to combat Bird Flu. The Ministry of Agriculture plans to open a telephone hotline later this month to aid public awareness of the issue. 

Indonesia reports 69th H5N1 case
Sep 29, 2006 

Indonesia reported its 69th H5N1 avian influenza case today, in the 21-year-old sister of an 11-year-old boy who died of the same disease on Sep 18. 

The woman from the Tulungagung district of East Java tested positive for H5N1 today, 4 days after she was hospitalized, according to a Bloomberg News report. The World Health Organization (WHO) confirmed her 11-year-old brother's case on Sep 25. 

The WHO had reported that poultry in the boy's household began dying in the month prior to symptom onset, and poultry deaths continued in his neighborhood. 

An Indonesian official said it was unlikely that the woman caught the virus from her brother. "They're genetically susceptible to the virus, which they were both exposed to from infected poultry," health ministry official I Nyoman Kandun told Bloomberg. He said there was no evidence that the virus was passed from one sibling to the other. 

Meanwhile, a 20-year-old man cited by the WHO as Indonesia's 68th case died yesterday, the WHO said. He is the 52nd Indonesian to die of the illness. 

The man was one of three siblings in Bandung, West Java, who had flu symptoms at the same time, which sparked concern about possible person-to-person transmission. His 23-year-old brother died Sep 24, and the WHO said H5N1 infection was suspected in his case, but it couldn't be confirmed because no samples were taken. Both men had fed dead chickens to their dogs, and there was evidence of H5 infection in household birds. 

The 15-year-old sister of the two men was hospitalized Sep 25 with a fever and cough and was hospitalized in stable condition, the WHO said on Sep 27. Initial tests pointed to normal seasonal flu rather than avian flu, the agency said. Indonesian health officials yesterday ruled out person-to-person transmission of H5N1 among the three siblings, according to an Agence France-Presse report. 

On Java island, avian flu disease may have infected a quarter of backyard poultry in some of the country's most densely populated areas, according an Indonesian veterinary official quoted in a Bloomberg News report today. 

Musny Suatmodjo, Indonesia's director of animal health, said random tests on Java, where the virus is most prevalent, detected the H5N1 strain in as much as 27% of fowl and caged birds. He gave no details about how many birds were tested or when the survey was done. 

"The backyard sector is the weakest link," he told Bloomberg News. "The survey of hotspots in the backyard sector showed almost every flock has been previously infected," though not all birds showed symptoms." 

In other avian flu news, China has shared some long-awaited samples of the H5N1 virus from birds, and many scientists are hailing the move as a breakthrough in cooperation, a WHO official said yesterday. 

The Chinese Ministry of Agriculture sent the samples, taken from some of the thousands of wild birds that died at Qinghai Lake in April 2005, to the US Centers for Disease Control and Prevention (CDC) in Atlanta, according to a Reuters report yesterday. 

WHO scientist Michael Perdue told a news briefing that the samples are the first bird specimens from China in two and a half years and will help researchers understand the origin of an H5N1 strain that later circulated in Turkey and Africa. The strain is genetically different from the one that moved through other parts of Asia, including Indonesia, Thailand, and Vietnam. 

The lake where the samples were collected is an important layover point for migratory birds in the remote northern Qinghai province, the Reuters report said. 

In March, China had promised to send up to 20 poultry samples to a WHO-affiliated laboratory outside the country. Samples were delayed because of reported communication lapses and disagreements between China and the CDC about the protocol and logistics for mailing the samples. However, the CDC said the problems were resolved in early September. 

Perdue said CDC officials expected to receive the samples yesterday, and he hoped the shipment would include additional animal samples requested from China, Reuters reported. 

"We have to wait to see exactly what they shipped," he said. 

China had not shared avian flu virus samples from poultry since late 2004, according to recent news reports. Poultry H5N1 viruses, especially those from China, are needed to develop vaccines and drugs. 

New Case Of Human Bird Flu In Egypt
9-27-6

Another case of avian flu in birds has been confirmed in Egypt. Ministry of Health officials and World Health Organisation (WHO) staff said on Wednesday that a case of H5N1 (avian flu) in birds was detected in a house near Aswan, in Upper Egypt. 

WHO spokesman Hassan el-Bushra told IRIN that the infected animals, raised in the backyard of a house in the town of Edfu, have now been culled. Ministry of Health officials have "instigated the WHO-approved control measures, and no human infection has been reported", he said. 

Animals within a one-kilometre radius of the site of infection have been culled and removed for sterile burial. 

This year, Egypt suffered the worst outbreak of avian flu outside Asia. The disease was largely brought under control, although fears remained of a new outbreak. 

The first announcements of avian flu cases among poultry in the country were made in mid-February. This lead to the culling of at least 20 million birds nationwide from that time to May, when alarm over the disease dissipated among the public. 

Fourteen human cases of bird flu have been found in Egypt since mid-March, al-Bushra said. Of these, six have died. The last was a 75-year-old woman who died on 18 May. 

Specialists say that the overwhelming majority of human cases in Egypt have been women who were infected by domestically kept birds. 

Soon after the announcement of the first cases of bird infections, a law was passed banning domestic breeding in urban areas. Health authorities did not push for similar restrictions in rural areas, however, where domestic breeding is more widespread and economically vital. 

"A ban [in rural areas] would lead many to conceal their birds, heightening the danger rather than quelling it," said health ministry press spokesman Abdel Rahman Shahine at the time. "Instead, we're working to help them increase awareness to prevent the emergence of new cases." 

Although health authorities sought to assure the public through various awareness campaigns that the consumption of cooked chicken was risk-free throughout the crisis, the collapse in demand and the mass culling combined brought the poultry industry to a standstill. 

Infections among birds were found in 20 of the country's 26 governorates, according to the health ministry, and until the latest case on Wednesday the situation was presumed to be under control. 

However, faced with the continued prospect of the virus mutating into a new, more dangerous form, health authorities have maintained safety measures. "Until the last virus is eradicated, the risk continues to exist," said al-Bushra. 

Indonesia Bird Flu Death Reach New High Of 51
9-26-6

More possible cases of bird flu have been identified in families in West Java and North Sumatra, triggering fears of new disease clusters, as the national death toll hit a record of 51 Monday. 

A 23-year-old male resident of Bandung died Sunday afternoon. His 20-year-old brother is in critical condition in an isolation room at Hasan Sadikin General Hospital. 

"Based on the symptoms, we suspect they are a new cluster," said Fatimah Resmiati, the head of the environmental health department at the West Java health office, Monday. 

Fatimah added that the elder brother died before he could be taken to a hospital for testing. 

"Unfortunately, we don't have his blood sample," she said.his leukocyte (white blood cell) level was only 1,600 and he was suffering from heavy pneumonia, which is usually confirmed as positive." 

The brothers' cousin said the brothers had fed their dogs dead chickens they bought from a nearby market. 

He said the younger brother developed a flu-like fever and breathing difficulties last Monday after feeding the dogs. His older brother then fell ill. The doctor who practiced near their house, however, believed it was only ordinary flu. 

As their conditions deteriorated, the brothers were taken to Santo Yusuf Hospital on Saturday night. They were transferred to Hasan Sadikin on Sunday because they were showing bird flu symptoms. 

Hadi Jusuf, who leads the bird flu team at Hasan Sadikin, said the remaining brother's condition had worsened since he entered the isolation room. 

"His leukocytes have continued to drop and the pneumonia in his lungs is more widespread. Because he has such difficulty breathing, we have attached him to a ventilator while giving him a high dose of Tamiflu," he said. Tamiflu, or oseltamivir, is a drug commonly used to treat bird flu. 

West Java has recorded the highest number of bird flu cases with 21 victims, of whom 16 have died. 

Meanwhile, five members of a family were being treated as suspected cases in Adam Malik Hospital in Medan, North Sumatera. 

Two of the children were released Monday, but another of the family's children, R.S., 11, died last Monday. Hospital spokesman Sinar Periangin-Angin said the family was admitted Friday for high fever. 

The cause of the fever was not clear, he said, but unusual chicken deaths had been reported within one kilometer of the family's house. 

The hospital's deputy director, Nur Rasyid Lubis, said the rest of the family appeared to be recovering. 

A ministry official, meanwhile, confirmed that the 9-year-old boy who died Friday in Jakarta was the country's 51st human fatality from bird flu. 

The boy, believed to have had contact with sick chickens, died in a hospital nine days after he first showed symptoms of the virus, including high fever and difficulty breathing. 

"By the time he arrived at the hospital, it was too late," I Nyoman Kandun, the Health Ministry's communicable disease director general, told AP. 

Confirmed H5N1 Bird Flu Cases In Indonesia Rise
September 13, 2006

Sulianti Saroso again received an assumption patient of bird flu, on Wednesday afternoon (15/3).The patient suspect bird flu that had the initials BS was the citizen of Housing Tarogong Beautiful, Bekasi, West Java.Casualties were 5.5 years beforehand old was treated for a week in the Hermina Hospital, Bekasi

The family admitted to not maintaining the poultry

Tests on the boy, from Bekasi in West Java, reported by the U.S. Centers for Disease Control and Prevention in Atlanta confirmed the H5N1 infection, said Runizar Ruesin, head of the health ministry's avian flu information center. The child died on March 19 and poultry deaths were recorded in the boy's neighborhood, Ruesin said. 
Almost all human H5N1 cases have been linked to close contact with sick or dead birds, such as children playing with them or adults butchering them or plucking feathers, according to the WHO.

The above translation from March, 2006 appears to describe the most recent confirmed H5N1 bird flu case in Indonesia. Like the most recent current case, it involves a child from Bekasi who is from a family that does not have a link to poultry. The number of cases in Bekasi continues to rise, but the link to poultry remains suspect.

All reported human H5N1 isolates from Bekasi have a novel cleavage site, yet none of the poultry isolates from Bekasi have this feature. To date only one avian isolate, from a duck from Indramayu has this change. However, although the bird isolate is from 2006, it is closely related to H5N1 from human cases from 2005. The more recent human isolates, including four from Indramayu in early 2006, have multiple changes that are not in bird isolates.

Thus, the linkage to poultry may stem from the testing, which is largely limited to those who have bird flu symptoms and have a link to dead or dying poultry.

Recently, the number of confirmed H5N1 cases in Indonesia has been limited to earlier cases. However, there have been reports of H5N1 positive poultry deaths throughout Indonesia in the past few weeks.

The lack of human cases may be due to testing delays or false negatives linked to aggressive use of Tamiflu.

H5N1 Cluster in South Sulawesi Indonesia
September 8, 2006

A student was 14 years old was named Akhira, was stated positive suffered bird flu. Akhira died on June 24, in the last three months, but results of his laboratory were just known, on Thursday (7/9).

Akhira personally, one among three insiders of one family that died. In a period less than two weeks, the domiciled simple family in……, Makassar, this hatus lost Andri Winarti (17) and his mother Hj Sukria (56).

All of them died after being treated with the complaint and the same sign, namely the fever, breathless, and the chest was sick. Kadis the South Sulawesi Health, Dr Andi Muhadir said, the hospital side when treating the three patients only took sample the bribe and blood from Akhira.

While Andri and his mother were not taken sample blood and his bribe to be researched in the laboratory.

The above translation indicates the confirmed H5N1 positive case announced by WHO today was a member of a family cluster (which was not mentioned in today's WHO Indonesian update). This latest result is simply more evidence that the monitoring of H5N1 in Indonesia remains scandalously poor and this poor surveillance is aided and abetted by the WHO.

In the same update, WHO acknowledged that the index case for Indonesia, an 8 year old girl who died over a year ago in July, 2005, is a confirmed case. Although this cluster has been obvious for over a year, WHO is confirming the index case a year after the fact, and the 1 year old dead sister is still not an official (or even suspect) case. 

Disease onset dates suggest the index case infected her baby sister and father. All three died within days of each other in July, 2005 and the first human H5N1 isolate, A/Indonesia/5/2005, came from the father, who prior to today was the official index case for Indonesia. All three family members were in initially diagnosed as bacterial pneumonia cases. However, eventually a sample was collected from the father that was H5 positive. The samples collected from the index case were negative for H5N1, but the patient had a titer of 320 as determined by Hong Kong and CDC. As second sample had an even higher titer (of 640), but since it was not 4 fold higher than the earlier collection (which was collected 3 days after the first sample), WHO considered the cases as “probable”. This classification made little sense since H5N1 had already been isolated and sequenced from the father by both Hong Kong and the CDC and there was little doubt that all three family members died from H5N1.

Unfortunately, even though this remarkable poor surveillance was in July, 2005, the same sequence of events is repeated again and again. The Karo cluster is officially the largest in Indonesia, but no sample was collected from the index case. More recently, media reports and the WHO update on the Garut cluster acknowledge the deaths of 3-4 contacts of H5N1 confirmed patients, but the earlier victims were never tested for H5N1 because they were misdiagnosed as typhoid cases.

The latest cluster above, appears to be more of the same. Although local media claims that this is the first case in South Sulawesi, a similar cluster in 2005 suggests H5N1 has been killing people in South Sulawesi for over a year, and poor surveillance / collection/ or testing has created yet another illusion on H5N1 in patients in Indonesia. 

Clusters are again not reported because samples are not collected and WHO updates appear to once again be out of touch with reality. Time and time again relationships between cluster members are described in local media, but absent from WHO updates. 

WHO failure to provide the most basic information (contacts or relatives who died and had bird flu symptoms), remains a hazard to the world’s health.

WHO confirms Iraq's third avian flu case
Sep 19, 2006 

The World Health Organization (WHO) has retrospectively recognized Iraq's third human case of H5N1 avian influenza, involving a 3-year-old boy who was hospitalized with a mild illness in March and recovered. 

The WHO says the boy was hospitalized in Baghdad but doesn't list his home, the source of his infection, or other details. 

The agency said shipment of test samples was difficult during Iraq's H5N1 outbreak, which is now considered over. The boy's initial test results were inconclusive, possibly because of sample deterioration during shipment. Repeated testing with different methods confirmed his infection, the agency said. 

The other two human cases in Iraq were fatal ones that occurred in January, involving a 39-year-old man and his 15-year-old niece from the northern province of Sulaimaniyah. H5N1 outbreaks in poultry were confirmed in the area in early February, and a WHO-led team was sent to the scene to assess the situation and support the local response. 

In other news, a World Bank expert recently proposed a new estimate of the global financial impact of a flu pandemic: $2 trillion. Jim Adams, who heads the World Bank's avian flu task force, made the projection at the annual meeting of the bank and the International Monetary Fund, according to an Agence France-Presse report 2 days ago. Adams said a severe pandemic could cut the world gross domestic product by more than 3%. 

Today, several news services reported an apparently peaceful military coup in Thailand, one of the countries hit hard by H5N1 avian flu in 2004 and 2005. In July, the disease resurfaced in poultry after an 8-month lull, followed by WHO confirmation of two new human cases, both fatal. 

Thailand's prime minister, Thaksin Shinawatra, has been under pressure to step down because of alleged corruption, according to a report today by Cable News Network (CNN). Also, media reports say a separatist insurgency has been raging in the Muslim south of Thailand since 2004, killing 1,700 people. 

In a Financial Times article 2 days ago, the United Nations' senior coordinator for avian influenza, David Nabarro, said the ongoing political crisis in Thailand may have weakened the government's response to avian flu outbreaks. 

"You don't maintain control over this disease unless there is regular top-level direction from a committed senior political figure that wants to be sure that the necessary activities are being undertaken," Nabarro told the Financial Times. 

Thailand has been without a fully functioning government since February, when the prime minister dissolved parliament to stem controversy over his family's financial dealings, the newspaper reported. 

Two Additional Cases Of Human H5N1 Infection In Indonesia
16 Sep 2006

The Ministry of Health in Indonesia has confirmed two additional cases of human infection with the H5N1 avian influenza virus. These cases occurred in March and May 2006.

The first case occurred in a five-year-old male from East Bekasi, West Java Province. He developed symptoms on 4 March 2006, was admitted to hospital on 6 March, and died on 19 March. Test results, using two different assays, showed high antibody titer for H5N1 on consecutive serum samples taken on days 11 and 15 of his illness. These test results are consistent with new WHO criteria for laboratory confirmation. A field investigation at the time found that the case was exposed to diseased poultry in the vicinity of his home, where some birds tested positive for the H5 virus subtype.

The second case is a 27-year-old male from Solok, West Sumatra Province. This case was identified during the tracing of contacts of the man's sister, a 15-year-old female who developed symptoms on 17 May 2006 and was subsequently confirmed to be H5N1 infected. Her brother spent six days caring for her during her hospital stay. The brother developed mild symptoms of cough and abdominal discomfort, with no fever, on 28 May 2006; his symptoms remained mild and he recovered within a few days.

Despite his mild and atypical symptoms, the brother was tested as part of the Ministry of Health's protocol for contact tracing and the management of any contacts with symptoms. He was given a five-day course of oseltamivir beginning on 1 June and was placed in voluntary isolation pending recovery.

Initial tests of samples collected from the 27-year-old male were negative for H5N1 infection. In August, follow-up testing of paired-serum samples found a fourfold rise in neutralization antibody titer for H5N1, a test result which meets the WHO criteria for laboratory confirmation.

The 27-year-old male reported no contact with diseased or dead poultry in the days prior to symptom onset as he spent most of his time at the hospital. The investigation determined that he had exposure to his sister during her hospital stay, and that human-to-human transmission could not be ruled out as the source of his infection.

The retrospectively confirmed cases bring the total in Indonesia to 65. Of these cases, 49 have been fatal.


Obstacle in bird-flu battle: black magic

Dowes Ginting, the most-wanted man on Sumatra island, lay dying. He had abandoned the hospital where he had seen relatives succumb one after another, and he had fled into the mountains, trying to outrun the black magic he feared had marked him next. For four nights, witnesses recalled, a witch doctor hovered over him, resisting the evil spell.

Ginting, 32, had watched disease burn through his family, killing six and sickening two others, including himself. International health experts grew increasingly concerned when lab tests confirmed they had bird flu, the largest recorded cluster of the disease. But Dowes feared medical treatment more than he did the flu. And so he ran, potentially exposing villagers across the province to the lethal virus.

In the end, the outbreak in May did not presage the start of a worldwide epidemic. But the difficulties specialists confronted in investigating the outbreak and protecting against its spread raised fundamental questions about whether bird flu could be contained if it mutated into a human form.

"If this were a strain with sustainable transmission from human to human, I can't imagine how many people would have died," said Surya Dharma, chief of communicable disease control in North Sumatra.

Officials from the World Health Organization (WHO) have suggested that a pandemic could be thwarted through a rapid containment effort, including the right mix of drugs, quarantines and other controls.

To succeed, the antiviral drug Tamiflu would have to be distributed to 90 percent of the targeted population. Residents would have to stay home, limit contact with others and take the medicine as prescribed.

In the case of the North Sumatra cluster, almost none of this happened, according to health officers, family members and villagers. The underlying problem was that most family members and many villagers were convinced black magic, not flu, was to blame.

More than 200 people worldwide have contracted the deadly H5N1 strain of the bird flu since 2004. Most cases have resulted from direct or close contact with infected live or uncooked poultry, or with surfaces contaminated by infected birds.

Health investigators have concluded that the eight-person cluster in Sumatra began with Ginting's older sister, who fell ill in late April. They suspect she was infected with bird flu from live chickens sold in a market or contaminated poultry droppings in manure used in her garden. She died and was buried before any samples were taken to confirm bird flu.

Family members fall ill

Several days after she became sick, the extended family gathered in the village of Kubu Sembilang for the annual harvest festival. That night, many of the relatives slept in the same room with the sister, who had developed a serious cough. By the time she died, a sister, a brother, two sons, a niece and a nephew had become ill. Flu specialists said the final victim, Dowes Ginting, in turn likely caught the virus from his son.

Health experts have concluded this was the first time the bird-flu virus was passed from one person to another and then on to a third person.

"None of us thought it was bird flu. We thought it was black magic," said Anestia Tarigan, the wife of the youngest Ginting brother, Jones, the only victim to survive.

Indonesian and WHO investigators discovered that many residents in Kubu Sembilang were unwilling to share information or give blood samples that could reveal how widely the virus was circulating.

Indonesian health officials, working with an international team, recruited 20 local volunteers to monitor fellow residents for fever and set up a temporary health post offering free medical care. The investigators methodically pieced together the chronology of the outbreak. They traced those who had contact with the victims and provided them with Tamiflu.

But many of those closest to the Gintings refused to take it. At the hospital in Medan, members of the Ginting family were unconvinced bird flu was what ailed them.

"They tried to refuse all treatment," said Nur Rasyid Lubis, the hospital's deputy director. "We could treat them only because their condition made it impossible for them to resist. But if they had been healthy enough to walk, they all would have run away."

Jones, the youngest sibling, did just that. He moved around Medan and the Sumatran highlands despite his fever and difficulty breathing. He returned after villagers told him the police were looking for him.

But he continued to resist treatment. Finally, doctors reached a deal with family members, allowing them to invite a witch doctor to the hospital in return for blood specimens from Jones Ginting.

Agenda Purba, a witch doctor from Jandi Meriah, chanted over 21 betel nut leaves, filled with blossoms, a pasty white lime, brown chunks of an astringent and bits of an orange-colored nut. He prayed for the young man's recovery, then chewed the first of the leaves and softly spit onto Jones' forehead. Purba repeated the process until he had finished the leaves, slathering the torso, arms, legs, hands and feet, making sure to cover all the joints.

"I'm the one to save Jones," Purba said. "There will be no more casualties."

Seeking a witch doctor

When Dowes Ginting developed a fever and began coughing, he fled in search of a witch doctor. Another medicine man in Jandi Meriah, Suherman Bangun, began the incantations and betel-nut spit treatment. After three days, Indonesian and international health investigators tracked the sick man to the village and urged his family to take him to a hospital. The relatives demurred.

That night, Dowes took an abrupt turn for the worse.

Shortly before dawn, Dowes rose to use the bathroom. Staggering, he could hardly breathe. His uncle lugged him to his SUV and set off for the district hospital. Before they made it, Dowes had died.

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