June 16, 2006 New York Times
Another Death in Indonesia Deepens Fears of Bird Flu's Spread
By DONALD G. McNEIL Jr.

The death of a 38th person from avian flu in Indonesia was confirmed yesterday by the World Health Organization and the situation in that country continued to worsen.

Indonesia is now in second place, after Vietnam, which has had 42 deaths, but none this year, while Indonesia's caseload is climbing rapidly and striking many family clusters.

The World Bank said Monday that Indonesia's response to the flu was disorganized and underfinanced. On Tuesday, the World Animal Health Organization said Indonesia was no longer even counting most poultry outbreaks. In the last year, it has officially reported the deaths of only 800 chickens, while there have been news reports of the deaths of thousands of birds from 29 of the country's 33 provinces.

Indonesia, the world's fourth-most-populous nation, has 242 million inhabitants and an estimated 1.3 billion chickens spread across 18,000 islands.

On Monday The Jakarta Post quoted several local health experts as saying that the government was not disclosing how widespread the disease was or how many times human-to-human transmission might have occurred. And last week Indonesia's health minister, Siti Fadilah Supari, said she was "running out of ideas for how to make the public aware" of the threat and get them to kill sick chickens instead of eating them.

Yesterday the Indonesian Health Ministry said the death of a 7-year-old girl in Banten Province on June 1 was the country's 38th from avian flu. The girl's 10-year-old brother died May 29, but he was buried before specimens were taken, so he was not included in the count. Chickens in the family's household had died earlier.

According to news agency reports quoting health officials, the 7-year-old had tested negative for avian flu in nose and throat swabs taken when she was alive, but then tested positive when lung tissue was taken after her death.

Nose and throat swabs the routine way of diagnosing regular flu may give false negatives because the bird flu virus attaches to cells deep in the lungs, not to the upper respiratory tract. In January, according to the World Health Organization, the same error caused the first human cases in Turkey's outbreak to be misdiagnosed.

Dr. Henry L. Niman, a biochemist who has questioned many of the health organization's official counts, argued that flu cases were underestimated because of that error and because blood tests could also produce false negatives if the blood was drawn before detectable antibodies had built up. Victims can die before that happens, and the outbreak in Indonesia has a very high death rate: of the 50 known cases, 38 have died.

An Indonesian newspaper, The Tempo, reported yesterday that one of its reporters who covered the extermination of infected poultry and the funeral of a flu victim near Jakarta had been hospitalized with flu symptoms; the newspaper did not report any test results.

**** Thompson, a World Health Organization spokesman, said he knew nothing about the reporter who fell ill, but he said the agency was drafting safety guidelines for journalists. "Some of them are getting pretty close to cases," he said.

There have been several reports of Indonesian nurses' falling sick after tending avian flu victims, which could indicate that the virus was spreading more easily between humans. On June 6, the World Health Organization reported that tests on four such nurses had convincingly ruled out A(H5N1), the avian flu, and indicated that one had a seasonal flu, A(H1N1), instead.

Dr. Niman said convincing evidence could be obtained only from blood tests.

Mr. Thompson, who recently returned from Indonesia, said that he did not know how the nurses had been tested, but that he thought that Indonesian health authorities "are really on top of the human cases, investigating them aggressively," even though animal cases were spiraling out of control.