Aug 21, 2006 (CIDRAP News) – A third human case of H5N1 avian influenza has been confirmed in a remote part of Indonesia where a number of suspected cases are being investigated, but most of the cases probably resulted from exposure to sick poultry, the World Health Organization (WHO) said today.

The confirmed case was in a 35-year-old woman from the subdistrict of Cikelet in West Java province who died shortly after she was hospitalized Aug 17, the WHO said.  She is the 46thIndonesian to die of the illness, out of 59 confirmed cases, by the WHO"e;s count. An Aug 20 Agence France-Presse (AFP) report identified the woman as Euis Lina.

Multiple cases in close proximity raise the possibility of human-to-human transmission.  The disease was confirmed in two other people from Cikelet in the past week: a 9-year-old girl who died Aug 15 and a 17-year-old boy who is still alive.

Three other people in the area died previously of suspected avian flu but were buried without being tested, according to Agence France-Presse (AFP). One of them was the daughter of Euis Lina, said Indonesian Health Minister Siti Fadilah Supari, as quoted by AFP.

Sixteen other people in the area have been tested for the virus, AFP reported today. Their initial results were negative, but the tests are being repeated, an Indonesian official told AFP.

WHO and Indonesian experts have been investigating in the Cikelet area since Aug 17, according to AFP. The WHO said investigators think the human cases are related to poultry outbreaks that began in late June.

Cikelet encompasses about 20 isolated hamlets of around 200 to 400 people each, situated in a basin surrounded by steep mountains and accessed only by rocky, winding paths, the WHO said.  People in the area have little access to healthcare and often die of endemic diseases such as malaria.

No mass poultry deaths are known to have occurred in the area before late June, when some chickens were bought from an outside market and added to local flocks, the WHO said. Large numbers of chickens began dying shortly afterward in an outbreak that continued through July and the first week of August.

"e;High-risk behaviors"e; cited
"As the population had no experience with this disease, high-risk behaviors commonly occurred during the disposal of carcasses or the preparation of sick or dead birds for consumption," the agency said. "These exposures are, at present, thought to be the source of infection for most confirmed or suspected cases."

Some people in the area died of respiratory illnesses in late July and early August, but no samples were taken and medical records are generally poor, the WHO said, adding, "Though some of these undiagnosed deaths occurred in family members of confirmed cases, the investigation has found no evidence of human-to-human transmission and no evidence that the virus is spreading more easily from birds to humans."

The Cikelet situation comes about 3 months after seven confirmed avian flu cases and one probable case occurred in an extended family in the Indonesian province of North Sumatra. That cluster brought the first laboratory-confirmed instance of human-to-human transmission and the first three-person chain of cases. However, the WHO concluded that the disease did not spread outside the family.

Indonesian officials today played down the likelihood of a case cluster with person-to-person transmission in Cikelet, according to the AFP report.

I Nyoman Kandun told AFP that the cases couldn"e;t be classified as a cluster at this point because the patients lived too far apart to have come into contact.

The 17-year-old boy who survived the illness had contact with a cousin who was one of the three people who died of possible avian flu without being tested. The WHO said previously that person-to-person transmission was highly unlikely in that instance because both patients were exposed to sick chickens and both got sick the same day, whereas there would have been a delay if one had been infected by the other.

Another suspected case-patient from the Cikelet area, a 4-year-old girl, was removed from a hospital today by family members against the advice of doctors, the Jakarta Post reported. After she showed some improvement, the family decided to treat her at home, though her test results were still awaited, said a spokesman for Dr. Slamet General Hospital in Garut regency.

The story described the girl as one of 11 people from Cikelet with suspected or confirmed avian flu.

The latest confirmed case raises the WHO"e;s global avian flu toll to 240 cases with 141 deaths. That includes 95 cases so far this year, equal to the total for all of 2005. Sixty-four people have died of the illness so far this year, compared with 41 for all of last year.

FAO lists Balkans as high-risk area
In other developments, the United Nations Food and Agriculture Organization (FAO) said today that the spread of avian flu among poultry has slowed in most countries, but warned that the southern Balkan countries and the Caucasus are a "high-risk region" for more outbreaks.

"The region is not only a prime resting ground for migratory bird species, but poultry production is mostly characterized by rural and household  husbandry with little in terms of biosecurity and strong regulatory inspection. In Romania it is still too early to say if the situation has stabilized," said Juan Lubroth, head of the FAO"e;s Emergency Prevention System for Transboundary Animal Diseases, in a news release.

The agency said H5N1 has been confirmed in 55 countries, up from 45 in April. But the virus"e;s spread among poultry has been slowed by efforts to improve surveillance, strengthen veterinary services, and, in some cases, vaccinate poultry, officials said.

"More than 220 million birds have died from the virus or been killed in culling activities aimed at stopping the spread of the disease," the FAO said.

To fight avian flu, the agency said it has received US $67.5 million so far and has signed agreements with donors for another $29 million. An additional $25 million has been promised. The FAO has disbursed $32.5 million since donor countries at a conference in Beijing last January pledged $1.9 billion for the campaign to stop the virus.