H5N1: Human to human

Human-to-human spread suspected in latest Indonesian bird-flu death 19:15:48 EDT May 22, 2006
HELEN BRANSWELL
(CP) - The World Health Organization appears to be edging closer to suggesting that an Indonesian man who died from H5N1 avian flu Monday may have been infected by his 10-year-old son, not through exposure to sick poultry or some other environmental source.
WHO officials had earlier expressed the theory that a thorough investigation might reveal a potential source of contagion in the community, such as use of contaminated chicken feces as manure. But expert disease investigators seem to be ruling out that possibility, a spokesperson for the WHO said from Geneva.

"There's no supporting evidence to suggest that this is a continuing environmental source that we've uncovered yet in the investigation," said WHO spokesperson Dick Thompson.
"The investigation is still ongoing. We wouldn't discount the possibility that it is human-to-human transmission."

Limited spread of the virus among people is believed to have happened on several previous occasions. But in each of these suspected cases, transmission of the virus petered out. Sustained human-to-human spread of the virus would be needed to trigger a pandemic.

Meanwhile, an Indonesian official revealed that the man who died Monday refused treatment and fled from authorities after falling ill - behaviour that highlights the difficulties of disease containment in settings where an unfamiliar disease is extracting a high death toll.
"This is precisely what we see, time and time again," medical anthropologist Barry Hewlett, a veteran of a number of WHO missions to contain outbreaks of Ebola virus in Africa, said of the panicked reactions Indonesian media have reported.

Reports have suggested fear and distrust have been running high in the affected community, which has watched in horror as multiple members of an extended family fell gravely ill in recent weeks, with most dying.

Dr. Heinz Feldmann of the Public Health Agency of Canada's National Microbiology Laboratory said in his experience fighting outbreaks of diseases like Ebola and Marburg fever, panic and distrust of authorities and medical outsiders is exacerbated when the death toll starts to rise.
"There are these white doctors who come in. Everyone thinks they're getting help, and then they're realizing they're not getting help. And everyone who goes into isolation (in hospital) is basically dying or a lot of them are dying," said Feldmann, a leading expert on hemorraghic fevers who heads the Winnipeg lab's special pathogens division.
"Then the community turns against you."

In cases dating back to late April, three of the man's siblings, two nephews, and two of his children became infected with the H5N1 virus. Only one family member who fell ill, a brother, has recovered from the infection.

The man's older sister, believed to be the first case in this cluster, died without being tested and is not on the WHO's official case count. With this latest case, the number of confirmed H5N1 cases in this family rises to seven, with six deaths.

The man, 32, is said to have nursed his son while the boy was dying, putting him in the path of blasts of virus-laced droplets.
When he himself became ill, he evaded authorities, the director-general of communicable disease control for the Indonesian health ministry told a news conference Monday.
"He ran away after he received Tamiflu," said I. Nyoman Kandun. "He was found in the village later but refused treatment."

Both Hewlett and Feldmann said getting people in such settings to co-operate with public health officials is a significant challenge that requires lots of communication with the community, sensitivity and a willingness to try to figure out what is motivating the behaviour.
Hewlett, a professor at Washington State University in Vancouver, Wash., recalls seeing Ugandans fleeing ambulances during a major Ebola outbreak in that country in 2000.
It turned out that there were rampant rumours that the team wasn't fighting disease, but was kidnapping Ugandans for body parts. The urban myth was fuelled by the fact that family members weren't allowed to visit their loved ones during their illnesses or after their deaths because of the fear of further spread of disease.

"My point is simply that you need to work with local people if you're going to make these things successful. Otherwise there's going to be resistance and the outbreaks will get worse rather than get better," said Hewlett, adding the WHO often now includes medical anthropologists or psychologists on outbreak teams as "social mobilizers" who can bridge the divide between the people affected and medical experts.

Feldmann said he can see another possible source of conflict with the Indonesian villagers - the fact that H5N1 control requires the culling of affected poultry. Demanding people give up animals they need, and which they often don't believe are a source of infection, can create tension, he suggested.
© The Canadian Press, 2006