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Indonesia Bird-Flu Victim Sought Witch Doctor, Shunned Hospital
posted by admin on 30/05/06

Indonesia Bird-Flu Victim Sought Witch Doctor, Shunned Hospital

``It's a good example of what the beginning of a pandemic outbreak might look like,''
May 26 (Bloomberg) -- Dowes Ginting died of bird flu this week in the arms of his wife in the back of a jeep as he was taken to the hospital. For three days he had evaded doctors seeking to test him for the virus that killed him and at least six of his Indonesian relatives, including his son. 

The movements of Ginting, a thin, boyish looking 32-year-old who grew limes, chilies and tomatoes in a northern mountain village of the Indonesian island of Sumatra, are part of a health probe that's attracting international attention. He and his relatives -- a brother, two sisters, two nephews, a niece and his son -- represent the largest reported instance in which avian flu may have been spread among people, investigators say. 

The World Health Organization says the Sumatran incident may mean the H5N1 avian influenza strain is becoming more adept at infecting humans, not just birds. Scientists are monitoring outbreaks like the one in Sumatra for signs the virus is evolving into a form capable of killing millions. 

``It's a good example of what the beginning of a pandemic outbreak might look like,'' said Ira Longini, a biostatistician at the University of Washington in Seattle. ``You would expect familial or hospital-based outbreaks and clusters.'' 

The WHO's disease-trackers are especially interested in the whereabouts of Ginting before he died to determine whom he risked infecting. He may have caught the virus from his son, who probably was infected by an aunt. This would be the first evidence of a three-person chain of infection, said WHO spokeswoman Maria Cheng in a telephone interview. 

Animal Source? 

Cheng said investigators have yet to identify an infected animal as a source of the outbreak. While that's not uncommon, direct contact with sick or dead birds is the principal cause of the human H5N1 infections confirmed by the WHO since late 2003, according to the United Nations agency. 

To date, the virus has sickened 218 people in 10 countries, killing 124 of them, the WHO said on May 23. Only a few cases may have been caused by exposure to other infected individuals. 

Health officials' difficulty tracking down Ginting for the three days leading to his death suggests that Indonesia may have trouble containing a human outbreak that might jump from affected villages to the rest of Southeast Asia. 

A pandemic starts when a novel influenza A-type virus, to which almost no one has natural immunity, emerges and begins spreading across the world. Experts believe that the 1918 pandemic, which killed 50 million people, began when a lethal avian flu virus jumped directly to people from birds. A similar outbreak may take more than 142 million lives and cause the world's economy to shrink by an eighth, a February report by the Lowy Institute and Australian National University found. 

Indonesia 

The chances of one emerging in Indonesia are higher because the Southeast Asian nation of about 240 million people has 30 million villages with more than 200 million chickens in backyards, according to the UN's Food and Agriculture Organization. 

``Indonesia is a very challenging situation,'' said William Hueston, director of the Center for Animal Health and Food Safety at the University of Minnesota in St. Paul. It's a ``huge country with a lot of different geographical units, and many working independently as I understand it.'' 

The Sumatra cases are being traced back to Ginting's 37-year- old sister, Puji, who worked selling limes at the Tiga Panah market about 5 kilometers (3 miles) from her home in Kubu Sembelang. 

She developed symptoms on April 27 and died of respiratory disease on May 4, according to the WHO. No specimens were obtained before her burial, and the cause of her death can't be confirmed, the agency said in a May 18 statement. 

Investigators Stumped 

It's possible the woman became infected from an animal source, said WHO's Cheng in a May 24 phone interview, ``but we've found no definitive evidence of H5N1 in any of the animals we've tested.'' The investigators comprise local health officials supported by five international experts, led by Tom Grein, a senior WHO epidemiologist based in Geneva. 

A preliminary investigation indicates that three of the infected family members -- Puji's two sons and another brother -- spent the night of April 29 in a small room when the woman was coughing frequently, the WHO said in a May 23 statement. 

Other infected family members lived in adjacent homes. All the confirmed cases can be directly linked to close and prolonged exposure to a patient during a phase of severe illness, the WHO said in its statement. 

Coughing 

It's less clear how Ginting's son was infected, Dick Thompson, leader of the WHO's pandemic and outbreak communications team, said by phone yesterday from the Indonesian capital, Jakarta. Based on neighbors' accounts, it's possible the boy entered his aunt's house during her illness, he said. 

Ginting helped care for his 10-year-old son at the Adam Malik Hospital in Medan up until the boy's death on May 13, the WHO said. Two days later, after returning to his home in Kubu Sembelang, Ginting began coughing. 

Ginting was examined three days later by local health-care workers, who observed avian flu-like symptoms. The WHO's Grein recommended on May 18 that he be isolated and treated in the hospital with the Roche Holding AG antiviral drug, Tamiflu. 

Instead Ginting fled local health authorities and sought care from a witch doctor, I Nyoman Kandun, director general of disease control with the Indonesian Health Ministry, told reporters in Jakarta on May 22. 

Disease Trackers 

Disease trackers located Ginting late on May 21 in a nearby village. Blood samples and swabs of his nose and throat for viral particles were taken that day and flown to a laboratory in Jakarta. Ginting died the following day after tests confirmed he had H5N1, the WHO said on May 23. 

There have been half a dozen examples of human-to-human transmission of H5N1, said the WHO's Thompson. In all of those examples, the virus had spread from one person to another and stopped. The difficulty in confirming human-to-human transmission is that it's sometimes impossible to eliminate other sources of infection in the environment, such as animals, he said. 

Ginting's actions and the local reaction to the deaths have health officials worried about how to contain outbreaks should the virus become contagious among people. Some residents of Kubu Sembelang said they resented the rapid assessment by some government officials that there was avian flu in the village. 

``The Minister of Health said that when the family got into the hospital they must be infected with bird flu,'' Veronita, a food vendor said in an interview on May 17. ``The results of the tests hadn't even been reported. Later the minister of health changed her words and said they `probably' have bird flu.'' 

Chicken Head 

To help instill confidence in the community, ``the district leader himself cut off the head of a chicken and had it cooked to prove that the poultry here are safe to eat,'' Veronita said. 

Dozens of poultry farmers and sellers from Ginting's district slaughtered chickens and drank the blood in Medan on May 22 in a demonstration of their frustration at being branded by authorities as having been infected with avian flu. Footage of the protests was broadcast on Trans TV television. 

``They're very afraid of losing their main income and that has become a problem for us in handling the disease,'' Bayu Krisnamurti, secretary of the national committee of avian flu control in the Southeast Asian nation, said in a phone interview on May 23. ``I don't want to blame them, but we must try to understand this is the situation,'' said Krisnamurti. 

Garnering Trust 

The Sumatra experience shows the government and international health authorities need to do a better job educating communities and garnering their trust, said Cheng. 
Ginting's wife, Bren, highlighted the family's suspicion and lack of understanding when she said in a May 17 interview that she believed Tamiflu poisoned her son. 

The WHO said this month that Tamiflu should be the first choice for doctors treating people with avian flu. 

The agency has mounted an international effort to get at the cause of the Sumatra incident and to establish the trust of the community, with experts flying in from the U.S. 
Centers for Disease Control and Prevention in Atlanta and from WHO offices in New Delhi, Bangkok, Geneva and Kuala Lumpur. 

Investigators also are following 33 people known to have been in contact with infected family members, Cheng said. Some of the people are taking Tamiflu to prevent the disease, she said. No other suspected cases had been reported, she said.

To contact the reporters on this story:
Jason Gale in Singapore at j.gale@bloomberg.net;
Karima Anjani in Jakarta at kanjani@bloomberg.net


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