Two more deaths from bird flu as Indonesia tries to track down souce of 'cluster' deaths

While Health officials in Indonesia are still trying to track down the source of infection in a cluster of six deaths in one family from H5N1 bird flu, tests show that two more people have also died of the same disease.

One of the latest victims belonged to the same Sumatran family, which lost several members earlier this month to bird flu, raising the concern of human-to-human transmission.

I Nyoman Kandun, director-general of communicable disease control at the Indonesian health ministry says the man is the father of the child who died on May 13.

He apparently ran away after receiving a Tamiflu shot and was later found in the village but refused any further treatment.

Another death generally considered to be the initial case of the cluster in the village in north Sumatra, cannot be confirmed because no samples were obtained.

The woman died three weeks ago but health officials are no closer to finding the source of the virus despite quite vigorous testing of chickens, ducks and pigs in the neighbouring district as well as the immediate surrounding area.

Kandun said a 38-year-old man from Jakarta who died last week had also been declared positive for bird flu by local tests and at this stage human-to-human transmission cannot be conclusively confirmed or dismissed.

Experts with experience of getting people in such settings to co-operate with public health officials warn of the significant challenge facing health workers, requiring good communication with the community, sensitivity and an eagerness to understand the local situation.

Five of the man's relatives have been confirmed as dying from bird flu by the World Health Organisation (WHO) and another family member has survived the infection; it is not uncommon for people in such a situation to panic and fear intervention from outside agencies.

The WHO because of past experience with outbreaks such as the Ebola one, now often include medical anthropologists or psychologists on outbreak teams as "social mobilizers" who can bridge the divide between the people affected and medical experts.

Another problem may be convincing Indonesian villagers that H5N1 control necessitates the culling of affected poultry, often their only source of income and a vital food supply.

At this stage the movement of diseased poultry is suspected to have played a role in the events and supports repeated calls from experts for stronger measures to stem such movement.

Some infectious disease experts believe that because so many people have been infected it is an indication that a lot of poultry is infected and they say what usually begins with chickens transfers to pigs and then to humans.

But local scientists have yet to test samples specifically for N1 antibodies which might indicate they were infected with H5N1 some time in the past.

In order to achieve definitive results testing can take up to two weeks for H5N1 antibodies to be traced.

The WHO has confirmed 32 fatalities from avian influenza in the world's fourth most populous nation, the second highest number of human deaths after Vietnam and also will not discount the possibility that human-to-human transmission of the virus has occurred.

A limited spread of the virus among people is suspected to have happened on several previous occasions but in each case transmission of the virus simply petered out.

It seems sustained human-to-human spread of the virus is needed to trigger a pandemic.

H5N1 remains largely a bird disease, and is at present is only contracted by contact with diseased birds, but experts have been warning for some time that it might mutate and pass efficiently between humans and cause a global pandemic.