# 2976
The actual number of human cases of H5N1 bird flu in Indonesia is unknown, and has been unknowable from the start.
It is the same for just about every disease, really. And not just in Indonesia, although countries with poor surveillance systems are more likely to miss cases.
The chart above is one used by our own CDC to show why the number of confirmed cases (of just about every disease) generally only reflects a small percentage of the actual cases in the population.
Here in the United States, we only have a rough idea of how many West Nile Infections, or Lyme Disease Cases, occur each year. It is the same with nearly every disease in every country.
Accurate counts just never happen.
The unknowns, when it comes to H5N1 include:
- How many people (if any) experience mild (or sub-clinical) symptoms and never seek medical help?
- How many people simply die, are buried, and are never tested for the virus?
- How many people are misdiagnosed, and either survive or succumb with the wrong diagnosis?
- How many exclusions occur due to false negatives during testing?
As you can see, a great many things have to go right before a patient ends up in the `confirmed’ category.
The idea that there must be mild, possibly even asymptomatic, human infections continues to evoke controversy.
It `makes sense’ and it would lower the current astronomical CFR (Case fatality ratio) to something more `reasonable’, but so far, we’ve precious little scientific evidence (in the form of seroprevalence studies) to back it up.
It remains an open question.
We’ve certainly seen cases where a family member gets sick, dies, and is buried without testing, only to have another family member fall ill and test positive for the virus a week or so later.
Coincidence? Possible, but unlikely. Still untested cases – no matter how suspicious - are never counted.
And we’ve heard of cases that tested negative 3- 4 – 5 – 6 . . . even 7 times, only to finally return a positive test for H5N1 – sometimes only during an autopsy when deep lung tissue biopsies are available.
Continued testing after returning 2 or 3 negative results is rarely done, however, and usually only when a doctor believes the patient’s symptoms are indicative of H5N1 even when the tests say otherwise.
Testing for the virus has always been difficult, and can be made even more so by the administration of antivirals, poor sampling techniques, or improper handling of samples during transport.
So no one should be terribly surprised when the claim is made that we don’t really know how many bird flu cases have occurred in Indonesia . . . or any place else in the world.
The case counts, hopefully, give us some idea as to the trend in each country. Whether cases are on the increase, or decline.
But that’s about all they do.
We can make some guesses about the prevalence of a disease based on this tip of the iceberg, but they are in the end, just guesses.
Obviously, some nations will be better at surveillance and testing than others. There are areas of Sub-Saharan Africa, and remote areas in Asia, where medical facilities and sophisticated lab tests are practically unheard of.
People in these places no doubt die from a variety of diseases (of which, H5N1 could be one) without ever receiving medical care. But we’ll never know for sure.
And then . . .there’s the elephant in the living room.
Nations (or sometimes just local regions within nations) that attempt to hide, minimize, or cover up cases.
We know it happens.
Indonesia’s Health Minister Supari has actually come out and admitted that they seek to minimize publicity about bird flu in their country, and have therefore decided not to release information about cases as they occur.
The Health Ministry has provided no updates (thus far, anyway) on cases from 2009, yet representatives of another agency from Indonesia KOMNAS (The National Bird Flu Commission) has publicly alluded to there having been at least 6 fatalities this year.
Judging by the news reports, that tally is probably low.
There are genuine questions over the release of information from China as well. In January, they reported 8 human infections, and then since that time . . . not a word.
Dissident news reports, however, paint a different picture.
Those reports are unverifiable, of course, and the dissident agencies are not without an agenda. It’s very hard to know how much credence to give them.
China’s track record on disclosing `negative’ information has always been poor, however. Memories of their brazen attempts to hide the SARS outbreak in 2003 still linger in the minds of public health officials.
Myanmar, North Korea, and Iran are three more nations that have seen the H5N1 virus in the past, and whose surveillance and reporting to International agencies is suspect.
Indonesia has shown other nations that `nothing bad’ has happened to them when they flout International law and fail to report bird flu cases in a timely basis.
They’ve not filed an OIE report on poultry outbreaks since September 2006, they’ve withheld virus samples from the WHO (World Health Organization) for more than 2 years, and they refuse to acknowledge human cases until months after they occur.
Even then, the numbers they provide are suspect.
From Indonesia’s perspective, it makes sense to downplay any bird flu problem. It’s bad for business and it’s bad for tourism, and constant media coverage of an unremitting public health problem is bad for politicians in power.
Other nations are no doubt taking note.
Last year, the number of human H5N1 cases confirmed (and admitted to) by governments around the world dropped dramatically. Many people hailed this as a sign that the bird flu threat was waning.
It would be nice if that were true. And perhaps it is.
But to really believe that, you’d have to believe that efficient surveillance, and honest reporting are both universal.
And there is serious evidence of lack in both of those areas.
Yesterday, during an appearance on the Good Morning Egypt television show, the Deputy Minster of Health, Dr. Nasr accused nations like Indonesia and China of a `media blackout’ on their bird flu situation.
Strong words, particularly coming from a government official, but an opinion that he is not alone in holding.
A hat tip to Sally on Flutrackers for finding, and translating, this report from the Arabic EGYNEWS.NET.
Fifty thousand of the leading rural and early reporting of bird flu
The basis of the domestic bird infections Deputy Minister of Health said more than 13 thousand rural pilot based on the awareness-raising within the village for the prevention of bird flu as the rate of home visits per day to more than 50 thousand house said, adding that early detection of disease, leading to the death of any bird's by 2009.
Dr. Nasr said Mr. program Good Morning Egypt on Saturday morning that a number of countries do not have a true and accurate monitoring of the disease also has a media blackout, such as China and Indonesia.
The Assistant Minister of Health said the cases were detected because of the speed of reporting after the success of campaigns to raise awareness of rural women, but he stressed that local efforts must be doubled in order to define the seriousness of the women's children mixing poultry.
For now, the best we can do is report the cases that come to our attention, even though they may not be confirmed, or even acknowledged, by their respective governments.
Many, no doubt, will turn out not to be H5N1.
That is to be expected, and suspect cases should always be treated as such – suspect.
There are a great many ILIs (Influenza-Like-Illnesses) running around that can mimic bird flu, and so we can’t assume every negative test is a `false negative’.
But as we count cases, and try to determine trends, we also need to be aware that we are not seeing all of the pieces of the puzzle. And we therefore need to be very careful about jumping to conclusions.
Which is why I try not to get too hung up on individual case counts. Going in, we know they will be incomplete (and perhaps even misleading).
The good news in all of this is, that despite the gaps in our knowledge and the inaccuracy of our counts, we’ve yet to see any evidence of sustained, efficient H-2-H (Human to Human) transmission of the virus.
Sporadic cases can be missed, or perhaps even hidden, but large outbreaks would undoubtedly show up on our radar screen.
That could change at any time, of course. The virus continues to evolve and to spread.
Which is why, as long as the virus is out there, we need to keep looking.
