May 22, 2006 (CIDRAP news) – Local tests indicate that two more Indonesians have died of H5N1 avian influenza—one of them from the extended family case cluster still being investigated in northern Sumatra, according to news reports.

In addition, according to an Associated Press (AP) story today, a third Indonesian, in East Java, has tested positive but remains alive. And Reuters reported today that two Iranians have died of H5N1 infection, which, if confirmed, would be Iran"e;s first human cases.

The victim in Sumatra, a 32-year-old, is the father of one of the earlier victims, a 10-year-old boy. "He is the father of the child who died on May 13," said Nyoman Kandun in an Associated Press AP story today. Kandun is the director-general of disease control for Indonesia"e;s Ministry of Health.

Last week, the World Health Organization (WHO) confirmed that six people in the man"e;s extended family had been infected with H5N1 and that five of them had died. Another person, a 37-year-old woman who was the first in the family to die, was not tested but had symptoms of avian flu and is considered the index case, according to the WHO.

Kandun, according to the AP, said the 32-year-old who died had received oseltamivir in the hospital, but then ran away. He was later found in his village but refused antiviral treatment.

News agencies report that the other confirmed case of avian-flu-related death occurred May 19 in the capital city of Jakarta. No further information on this fatality was available as of this writing.

The third case involved an 18-year-old shuttlecock maker in East Java, according to a May 21 Reuters story. He is currently hospitalized and undergoing treatment for avian flu, according to Reuters. Investigators are tracing the source of the feathers he used for making shuttlecocks, Kandun told Reuters.

If all these cases are confirmed by the WHO, Indonesia"e;s avian flu case total would rise to 44, and its death toll would reach 34. Indonesia has reported by far the most H5N1 human cases and deaths in 2006.

Investigation of the Sumatra cluster by scientists from the WHO and the US Centers for Disease Control and Prevention continues. A source of this outbreak has not been found; local chickens, ducks, and pigs have all tested negative for H5N1.

Human-to-human transmission is a concern in any cluster, but especially one this size. "We cannot confirm that [human-to-human transmission] has occurred," the AP quoted Kandun as saying in today"e;s story, "but we cannot rule it out."

Reported cases in Iran
In Iran, tests on the bodies of a 26-year-old woman and a 41-year-old man confirmed H5N1 infection, according to a hospital official in the northwestern province of Kermanshah, as reported today by Agence France-Presse (AFP).

"Four people have been hospitalized, among them a woman and her husband who have died," the head of the university hospital in Kermanshah told Iranian Students News Agency, according to the AFP story. "Another one of those hospitalized is in critical condition," he added. "There are suspicions of bird flu symptoms."

"Their tests have been sent to medical centers inside the country and abroad to clarify the issue," said the official, identified only as Dr Izadi, according to AFP.

Though the patients are identified as husband and wife in the AFP story, a Reuters report published today lists them as brother and sister.

If the tests are confirmed, these would constitute the first human cases of avian flu in Iran. The first report of H5N1 avian flu in Iran came in February, when officials said 153 wild swans had died of the disease.