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The following report has been cobbled together from a combination of news sources, some local to Sumatra and others international.

A large cluster of H5N1 cases among an extended family in the Indonesian province of North Sumatra, on the island of Sumatra, has health officials around the world concerned. Reports from the location have been incomplete and conflicting, but the following is the best information available as of Sunday evening.

In a village about 175 kilometres south of the provincial capital of Medan, 7 or 8 members of an extended family were hospitalized more than a week ago with suspected bird flu. On 12 May 2006, Pengendalian Breakingprep Penyakit, director general of the North Sumatra Department of Health and Environmental Sanitation, confirmed that at least 5 of the 8 suspected bird flu cases had tested positive for the H5N1 virus in local testing. Samples have been sent to a WHO-affiliated lab in Hong Kong for verification.

Some local news sources stated that the family lived in the same small home, while other sources indicate that they lived close to one another in the same village, but in different homes. In any case, the family was taken to Medan (the provincial capital) for hospitalization at the RSUP (Central Public Hospital) Adam hospital.

The first death to come to the attention of the international community was [a 19 year old man, the index victim], who died Tuesday, 9 May 2006, 11 days after first showing symptoms. His mother, [40 years old], had died on 4 May.

On Wednesday, 4 May, a woman aged 29 died at the hospital at about 5 a.m. local time. Her relationship to the others has not been clearly stated, though there is some indication that she may have been an aunt of the 19 year old man. She was identified by some local sources as living in Kabanjahe, the capital of the Karo Regency (district), and not in the village where the others lived, but the accuracy of this last statement is not known.

A 18 year old man, brother of the index victim, died on 12 May.

A boy, age 8 (some sources said 10), died Saturday, 13 May, at about 2 p.m. local time, at RS Elizabeth hospital, also in Medan. This may be the individual identified by some news sources as a cousin of the index man, a child aged 8. This also may be the source of reports that 8 members of the family were hospitalized, rather than the 7 for whom we have identification.

A baby boy aged 18 months was originally reported as having died on Friday 12 May, but it was later learned that he did not die until Sunday 14 May. This date of death was confirmed Sunday by I Nyoman Kandun, director general of disease control at the health ministry.

On 13 May, local media reported panic in the region (but, if there were panic, it likely was in the Karo district rather than in Medan itself). They also reported that the 2 surviving members of the original family were transferred to RS Elizabeth after they attempted to flee the hospital. The accuracy of these reports of attempted flight have not been verified, but it is known that the 2 survivors (not the toddler) were transferred to RS Elizabeth, where one of them died on 13 May. Other sources reported that the 2 were released from hospital, but hospitalized again after their conditions became worse. This last report seems far more unlikely than that they attempted to flee.

Both local and international media reported that one or more family members originally contracted the disease from contact with contaminated fertilizer. According to local sources, the family often bought manure from 2 unidentified vendors whose poultry had recently been found positive for the H5N1 virus.

On 12 May, in addition to reporting 2 deaths (one of which did not happen), local sources also reported that 12 people remained hospitalized in RSUP Adam with suspected bird flu symptoms. It was not stated if these people were other relatives, friends and neighbors, or just what their exact association with them was.

These sources also reported that, worried by the spread of the disease, the provincial government of North Sumatra ordered the Karo district health service to sterilize the family's home along with an area of 1 kilometre radius surrounding it. This also means culling or vaccinating all poultry in that area.

WHO officials in Indonesia said Sunday that tests of livestock in the village showed positive results for the H5N1 virus and now poultry and swine in the village are being tested. No indication was given if by "livestock" the WHO meant cattle, nor why (if it does mean cattle) these animals were tested before poultry and swine, both of which have stronger indications for infection than do cattle.

This outbreak is the largest familial cluster reported in Indonesia to date. It also may be the largest familial cluster ever reported for the H5N1 virus and has international health officials worried that the disease may be mutating to become more easily transmitted between humans.

H5N1 has been in Indonesia since 2003. The first human infections, however, were only reported in 2005.

There are many issues involved in getting news of this outbreak out of Medan and North Sumatra. First, is the problem that local news sources are all in Indonesian, which not only is a different language, but even has a different character set (alphabet) from English. Second, the accuracy of local news sources is highly questionable. Third, both hospital and government officials may not always be forthcoming with information about victims or the course of the disease.

Readers also should be aware of the following language issues with reports coming out of the North Sumatra area: Karokaro is sometimes transliterated as Karakar or as Karo-karo; Beru is sometimes transliterated as Boru, and is often abbreviated as Br.

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It wasn't immediately clear whether the family members had been exposed to infected poultry. Dr Kandun said that the family had at least a few chickens, 2 of which died recently, although birds often die in small numbers for reasons other than avian influenza. He said barbecued pig had been served at the family gathering. [Note this differs from the fertilizer hypothesis.]

WHO has sent an official to the family's village to investigate. "The investigation is still ongoing. It's still too early to say at this point," Sari Setiogi, a spokeswoman in Jakarta for the agency said last night, adding that this was the largest cluster she has seen. "It's a huge number of people that are living in the same place. But the possibility of environmental exposure is also there."

A nurse who attended to some of the patients also came down with an influenza-like illness, although she seems to have shown symptoms prior to treating the patients, according to Dr Kandun. She and others in the family's village are currently being tested for the virus. While there have been no obvious signs of poultry infected with bird flu in the area where the people died, according to Dr Kandun, the virus has been widespread among the country's birds. Many human cases of bird flu have been confirmed in places where there have been no reported infections among poultry. Birds are known to harbor the virus without showing symptoms, and cases of the disease in birds might go undetected.

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Bird Flu Possibly Spread Among Humans

By Anthony Deutsch
Associated Press
posted: 24 May 2006
11:44 am ET

JAKARTA, Indonesia (AP) -- The U.N. health agency described the deaths of six Indonesian family members from bird flu as the most important development in the spread of the virus since 2003, saying it is investigating whether the disease has spread from person to person.

"We have a team down there, they are examining what is going on and they can't find an animal source of this infection,'' said Peter Cordingley, spokesman for the Western Pacific region of the World Health Organization.

"This is the first time that we've been completely stumped'' by a source for the infection, he said.

Six of the seven people in an extended family in northern Sumatra who caught the disease have died, the most recent on Monday. WHO is investigating whether the H5N1 strain of bird flu was spread among family members, though it said Wednesday there was no evidence the virus had mutated to a form that will spread more easily between humans, possibly sparking a pandemic.

Steven Bjorge, the WHO team leader in the village of Kubu Sembelang, said none of the poultry in the area had tested positive for the H5N1 bird flu virus.

"We're not surprised that there is possible human-to-human transmission,'' Bjorge said. "The thing we're looking for is whether it's sustained beyond the immediate cluster.''

Isolated cases of very limited human-to-human transmission have been documented -- including one in Thailand involving a mother and child -- but such cases do not mean a pandemic flu strain has emerged. There was no indication the Sumatra infections had spread to anyone outside the family.

Still, the scenario worries scientists.

"No matter what's going on at this stage, it's a limited transmission between members of the same family,'' Cordingley said from Manila, Philippines.

"What we are looking out for is any sign of this virus going outside of this family cluster into the general community, that would be very worrying. We haven't seen any signs of that yet.''

Bird flu has killed 124 people worldwide, more than a quarter of them in Indonesia. So far, most human cases have been traced to contact with infected poultry.

Bjorge said the virus that infected the family members was genetically the same as the one found circulating in the area earlier. Tests are still being carried out on poultry in the village.

Peter Roeder, an animal health expert from the U.N. Food and Agriculture Organization in Rome, said tests so far had been negative for the virus, but antibodies were found in some specimens taken from chickens and ducks.

. . .

Bjorge said the woman first believed to be infected worked as a vegetable vendor in a market where live poultry was sold.

Experts are trying to determine if that's where she became infected. The woman, who died May 4, was never tested for the H5N1 virus, but WHO considers her part of the family cluster. The woman's 25-year-old brother is the only family member still living after being infected.

"All confirmed cases in the cluster can be directly linked to close and prolonged exposure to a patient during a phase of severe illness,'' the WHO said in a statement on its Web site.

Bjorge said some samples have been taken from villagers, but that local authorities have resisted working with outside health experts. WHO has enlisted local villagers to help monitor the village for anyone experiencing flu-like symptoms.

If anyone is found to have even mild symptoms, they will be quarantined and given the anti-bird flu drug Tamiflu, he said.

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WHO: No urgent meeting on bird flu

Wednesday, May 24, 2006; Posted: 9:50 a.m. EDT (13:50 GMT)

JAKARTA, Indonesia (Reuters) -- Limited human-to-human transmission of bird flu might have occurred in an Indonesian family and health experts are tracing anyone who might have had contact with them, the World Health Organisation said.

But a senior WHO official said in Jakarta this was not the first time the world was seeing a family cluster and said that fresh scientific evidence has shown the virus in Indonesia has not mutated to one that can spread easily among people.

WHO said on Wednesday it had no immediate plans to call a meeting of experts to discuss raising its global bird flu alert.

"Right now it does not look like the task force will need to meet immediately, but this is subject to change depending on what comes out of Indonesia," WHO spokeswoman Maria Cheng said, when asked to comment on press reports of an imminent meeting.

Financial markets, however, were spooked on fears the Indonesia cluster could be the start of a pandemic. Currencies in Asia, where most bird flu cases have occurred, fell. U.S. commodity prices came under pressure while European markets slipped as investors turned jittery.

Concern has been growing about the case in north Sumatra in which seven family members from Kubu Sembilang village died this month. The case is the largest family cluster known to date.

WHO and Indonesian health officials are baffled over the source of the infection but genetic sequencing has shown the H5N1 bird flu virus has not mutated, the U.N. agency said on its Web site (http://www.who.int) on Tuesday.

Nor was there sign of the virus spread among villagers.

. . .

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The only remaining member of a family
killed by bird flu is treated in
Indonesia's Northern Sumatra province.