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Task Order 2Avian Influenza in

IndonesiaJuly 1, 2008Briton Bieze

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Overview

• AI globally• AI in Indonesia• USAID | DELIVER PROJECT activities• Challenges and Lessons Learned

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Cases of human Avian Influenza Worldwide

• 385 Cases of human AI as of June 29, 2008– 243 have been fatal

• 135 cases of human AI in Indonesia– 110 have been fatal

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So why so much effort into containing AI?

• Human deaths• Economic loss – poultry deaths, job losses,

production loss from human deaths and illness and less protein intake, less tourism

• Potential of human pandemic – estimate morbidity and mortality in the millions

• Potential of economic and societal losses if human pandemic occurs

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Worldwide Status of HPAI H5N1Between Nov 2003 and May 9, 2008

H5N1 detected in birds in 60 countries - 6,414 poultry outbreaks reported - more than 250 million birds have died or been culled - at least 32 bird and 8 mammalian species affected - affected countries in Asia, Europe, Near East, Africa

H5N1 detected in humans in 14 countries - total of 385 cases and 243 deaths reported - average of 5-9 new cases per month - overall fatality rate = 63%

sources: WHO, OIE, GenBank

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Areas reporting confirmed occurrence of H5N1 avian influenza in poultry and wild birds since 2003, status as of 14.04.2008

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Pandemic Status

• HPAI-H5N1 already causing a “pandemic” among bird populations on 3 continents

• HPAI H5N1 has evolved into 9 different sub-groups between 1996 and 2008; birds still main host

• H5N1 human infections are still relatively rare; almost all from bird-to-human transmission

• Some human-to-human transmission of H5N1 likely but limited and unsustained in these cases

• WHO’s current pandemic threat level is 3 (on a scale of 1-6 with 6 being a human pandemic)

sources: WHO, OIE

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Risk Factors Associated with Poultry H5N1 Infections

• Large and dense poultry populations• Poor biosecurity on farms (especially large, commercial farms)

and in wet markets• Proximity to or trade with highly-affected areas especially

where there is poor regulation of poultry movement (including ducks and vaccinated chickens)

• Weak H5N1 surveillance and outbreak investigation capacities• Slow detection and outbreak response times and incomplete

containment (including limited culling, compensation, surveillance, movement control)

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Risk Factors Associated with Human H5N1 Infections

• Number/timing of human cases and poultry outbreaks in a country consistent with bird-to-human transmission of H5N1– At least 44% of human cases known to have had contact with sick

or dead birds before onset of symptoms

– At least 19% of cases had at least one other family member who was also a confirmed H5N1 case indicating shared risks and/or genetic vulnerabilities

– Cases and deaths evenly distributed between males and females in most countries including Indonesia

• At least 11 cases of likely but limited and unsustained human-to-human transmission of H5N1 in 4 countries

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Indonesia Country Overview

• Large populations:– ~1.4 billion poultry– ~225 million people

• Decentralized systems:– budgets and decision making– disease control

• Widespread disease:– H5N1 circulating in Indonesia between 2003-2008– H5N1 detected in about 31 of 33 provinces

• Data limitations:– Limited poultry outbreak and H5N1 sequence data (temporally and

geographically)– Limited behavioral and treatment data for human cases

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Distribution of Confirmed H5N1 Human Cases by Province (2005-2008)

Province

Data from WHO reports through 5/9/08. Indonesia total = 133.

Sumatra Java 68% of confirmed H5N1 human infections in 3 provinces of Java (Banten, Jakarta, West Java)

W. Java has large poultry and duck populations and poultry outbreaks in 2007

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Indonesia Poultry Production

• Indonesia not a significant exporter of poultry • Poultry movement within and among islands common• Mass vaccination of poultry common in commercial sector;

many vaccines available and coverage and dosing not uniform• Existing poultry surveillance appears to not cover all provinces

or all poultry production sectors • Reported to be ~13,000 Live Bird Markets in Indonesia• Co-mingling of poultry, wild birds; poultry slaughter done on

premises• High-risk factors exist for AI spread among birds and to humans• Unsold birds sometimes returned to source• H5N1 detected in some markets

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USAID | DELIVER PROJECT’s Scope of Activities in Indonesia: 2007 – present

• Personal Protection Equipment (PPE) and Decontamination Kit pre-positioning

• Support to Komnas FPBI • Procuring commodities and providing logistics

support for Operational Research poultry vaccination activity

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PPE and Decontamination Kit Pre-positioning

• 203,350 PPE kits donated to Government of Indonesia since January 2007– 55,868 distributed by UNFAO to Ministry of Agriculture for

outbreak investigations– 31,775 distributed by CBAIC to its partners– 290 given to Komnas FBPI– 10,000 on reserve for Komnas FBPI for emergency use

• 997 decontamination kits donated to Government of Indonesia since January 2007– 301 decon kits and 501 pails of disinfectant distributed by

UNFAO to Ministry of Agriculture for outbreak investigations

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Support to Komnas FBPI

• National Committee for Avian Influenza Control and Pandemic Influenza Preparedness

• 10,000 PPE on reserve for emergency• For PPE stockpile, providing logistics system

guidelines with triggers for emergency use• Tentative discussions underway to provide Komnas

FBPI with a larger PPE stockpile, more detailed logistics system, and training on PPE and pandemic preparedness logistics

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Operational Research Poultry Vaccination Activity

• Operational Research (OR) activity being led by ILRI in collaboration with UNFAO and USAID | DELIVER PROJECT and other partners

• Funded by USAID and World Bank• Main objective to test systems of different containment

strategies• OR will assess success of 3 different AI control activities

targeting backyard poultry (against control group, PDSR program) – PDSR program with: AI mass vaccine; AI with Newcastle Disease (ND) mass vaccines; full compensation with culling

• Launch date set for July 7

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Partners

• ILRI– Leading OR– Research design– District profiling

• FAO– Instrumental partner– On the ground presence and MOA relationship– Vaccinator trainings, community mobilization

• USAID | DELIVER PROJECT

- Procurement • CBAIC

– VAICs and community mobilization

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USAID | DELIVER PROJECT and OR

• The project is procuring all commodities • Supplies include:

– AI and ND vaccine (total of 42.24 million doses)– Cold chain equipment, including refrigerators for 16 district

storerooms and cold packs, cold boxes and vaccine carriers for distribution to sub-districts

– Vaccination equipment, including automatic syringes, injection needles, safe waste disposal boxes, incinerators, and supplies for vaccinator teams

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Cold Chain

• Assisted UNFAO in conducting cold chain logistics assessment of district store rooms

• Through our sub-contractor, FHI and PATH, developed Quality Assurance plan for vaccine distribution

• Through our sub-contractor, PATH, provided cold chain logistics management training to provincial and district store room managers– Curriculum: maintaining cold chain for vaccines throughout

distribution, refrigerator maintenance, logistics management information system, waste management, supportive supervision.

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Challenges - OR

• Animosity between some partners• Need for strong coordination among partners• Lack of clear leadership and roles/responsibilities• Deliver’s relative late arrival in program• Procuring restricted commodities, including those over

$100,000 level – more requirements• Working through bureaucracy and in decentralized

system• Lack of cold chain system• Lack of staff on the ground and in-country support

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Successes - OR

• Partner differences resolved; USAID | DELIVER PROJECT has strong working relationship with all partners

• Cold chain system– Assessed– Personnel trained– Commodities procured and being delivered

• All supplies and equipment procured (and being delivered)

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Lessons Learned

• PPE ordering is a smooth process.• Preparations for OR activity are succeeding, but have

taken longer and been more complicated than expected – Documentation and USAID approval process for purchasing

restricted commodities – vaccines – is extensive– List of supplies for mass vaccination campaign is extensive

and must be procured globally and locally– Positive collaboration among partners is imperative – Clear leadership by USAID and good communication within

USAID and among partners necessary

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Pallet

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Cooler

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TERIMA KASIH!