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AVIAN INFLUENZA (H5N1) AVIAN INFLUENZA (H5N1) CONTROL AND PREVENTION CONTROL AND PREVENTION

IN INDONESIAIN INDONESIA

The Republic of Indonesia

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The Imperative is ClearThe Imperative is Clear“…“…all our development calculations and projections would all our development calculations and projections would be ruined, if humanity were to experience an avian flu, be ruined, if humanity were to experience an avian flu, human influenza pandemic. This could happen, if there is a human influenza pandemic. This could happen, if there is a mutation of the avian flu virus, that can spread between mutation of the avian flu virus, that can spread between humans. And this virus can mutate anywhere, in China, in humans. And this virus can mutate anywhere, in China, in Europe, in Southeast AsiaEurope, in Southeast Asia……The impact of a new pandemic The impact of a new pandemic on the economies of the world, would be totally on the economies of the world, would be totally disastrousdisastrous……That is why, we must all be on the high alertThat is why, we must all be on the high alert…”…”

Dr. Dr. SusiloSusilo BambangBambang YudhoyonoYudhoyonoPresident of the Republic of IndonesiaPresident of the Republic of Indonesia

In a speech to the In a speech to the Sixth Annual Conference of The Sixth Annual Conference of The ParlimentaryParlimentary Network Network

of the World Bankof the World BankHelsinki, Finland, 23 October 2005Helsinki, Finland, 23 October 2005

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Task is Enormous and ComplexTask is Enormous and ComplexLarge, geographically disbursed countryLarge, geographically disbursed country

Population 220 million, huge population of poultry Population 220 million, huge population of poultry high diversity of wild animals (especially birds), high diversity of wild animals (especially birds), large area to cover (1,9 million sq km)large area to cover (1,9 million sq km)AI endemic in 23 of 33 provincesAI endemic in 23 of 33 provinces

Highly decentralizedHighly decentralized400+ districts with elected local government400+ districts with elected local governmentHealth and Agriculture functions delivered by districts Health and Agriculture functions delivered by districts and provinces, with limited national controland provinces, with limited national control

Effectiveness of alternative options to control AI Effectiveness of alternative options to control AI at source still unproven internationallyat source still unproven internationally

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Avian Flu SituationAvian Flu Situation

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Indonesian Poultry Economy

Total InvestmentTotal Investment : US$ 35 billion: US$ 35 billionMoney CirculationMoney Circulation : US$ 30 billion/year: US$ 30 billion/yearManpowerManpower : 10 millions: 10 millionsDOC broiler prodDOC broiler prod : 1 billion/year: 1 billion/yearBreeding chickenBreeding chicken : 20 million: 20 millionLayer populationLayer population : 80 million: 80 million

Poultry Production StructureTotal poultry population: 1.3 billion

Sector 1 (Industrial integrated)Sector 1 (Industrial integrated)Sector 2 (Medium scale)Sector 2 (Medium scale)Sector 3 (Small scale)Sector 3 (Small scale)Sector 4 (Backyard farm)Sector 4 (Backyard farm)

80% poultry population

20% poultry population

30 mill households

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Chronology Chronology of AI Pandemic of AI Pandemic in Indonesiain Indonesia

Phase 1

Phase 2

Phase 3

Phase 4

Phase 5

Phase 6

July 05: Human infection confirmed

Inte

rpan

dem

ic

Pan

dem

ic A

lert

Pan

dem

ic

Aug 03: First Reported outbreak in poultry

19 Sept 05: “Status of Unusual Event” Declared

Indonesia is in phase 3

Prior July 2005

As of 1 November 05:

• The AI cases has spread to 8 provinces (in 4 most populous islands: Java, Sumatra, Kalimantan, Sulawesi)

• Total 40 cases resulting 15 deaths (33% fatality rate)

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As of October 2005

Since the first reported outbreak (August 2003), AI has spread progressively. As of August 05: 10,3 million poultry deaths

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Policy Direction,Policy Direction,Current Activities andCurrent Activities and

Problems FacedProblems Faced

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A Call for Action: A Call for Action: PresidentPresident’’s Instructionss Instructions

(20 September 2005)(20 September 2005)1.1. Quick and prompt measures on infected human and Quick and prompt measures on infected human and

poultrypoultry2.2. Prevent the spread of diseases through localizationPrevent the spread of diseases through localization3.3. Utilize fund from each ministry for prevention and cureUtilize fund from each ministry for prevention and cure4.4. Undertake public awareness campaignUndertake public awareness campaign5.5. Establish AI forum for synergizing efforts (*)Establish AI forum for synergizing efforts (*)6.6. Closely work with international communityClosely work with international community

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Agriculture Agriculture –– Current ActivitiesCurrent Activities1. Surveillance and virus spread mapping 2. Mass vaccination of 190 millions of poultry 3. Depopulation (selective culling) and compensation4. Increased biosecurity to prevent contact/spread.

Targets: commercial poultry production and backyard farms

5. Control movement of live poultry, poultry product and farm waste.

6. Public awareness and campaign on safe consumption of poultry products

7. Dissemination of guidance on AI prevention and control.

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Agriculture Agriculture –– Main Difficulties FacedMain Difficulties FacedSurveillance and Reporting:• Limited veterinary laboratories (only 7 regional labs),

Limited human resources vs area covered, including limited number of veterinarians at local level in most provincesLack of regulatory framework and mechanism for compulsory reporting from private sector and people at largeCurrent system: Field district province DG Animal Health (monthly & emergency 24 hours), but lack of capacity, funding, information make them not working properly.Early reporting from the local government not in place due to limited capacity and capability for early detection in the field

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Agriculture Agriculture –– Main Difficulties.. (contMain Difficulties.. (cont’’d)d)Vaccination of Poultry:

Evidence of efficacy not yet established –limited monitoring and evaluation, including weak vaccination recording (illegal vaccine circulation difficult to monitor; limited local production of vaccine) Limited coverage due to large area, small scale farms, limited equipment (syringe, refrigerator, etc) and storage capacity in province/districts

Culling:Level of financial compensation for depopulation doesn’t provide incentive for farmer cooperation –needs to be reviewed and clarified (low participation; appropriate procedure need to be established and followed)Difficult to effectively target in absence of good surveilance, monitoring and evaluation

Budget Constraint:Limited budget for surveillance and compensationLimited budget for surveillance and compensation2004 2004 RpRp. 11.7 billion . 11.7 billion atat 8 provinces, 238 districts (8 provinces, 238 districts (cullingculling 7 million 7 million chickenschickens))2005 2005 fewerfewer casescases

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Health – Current Activities1.1. Distribute guidance and dissemination of information Distribute guidance and dissemination of information 2.2. Active surveillance (probability of new cases, monitor of Active surveillance (probability of new cases, monitor of

closed contact person, investigation to find mode of closed contact person, investigation to find mode of transmission)transmission)

3.3. Taskforce of AI outbreak, monitor and report the Taskforce of AI outbreak, monitor and report the progress every dayprogress every day

4.4. Outbreak response: prepare 44 hospitals for confirmed, Outbreak response: prepare 44 hospitals for confirmed, probable and suspected casesprobable and suspected cases

5.5. Strengthen laboratory capacity (NHRD Lab)Strengthen laboratory capacity (NHRD Lab)6.6. Provision of antiProvision of anti--viral drug (viral drug (oseltamiviroseltamivir): 15.000 strips ): 15.000 strips

distributed to 33 provinces, 44 hospitals and 10 health distributed to 33 provinces, 44 hospitals and 10 health offices and for central stocking.offices and for central stocking.

7.7. PCR and serology testing for AI infected patients PCR and serology testing for AI infected patients 8.8. Provision of personal protection equipment to 44 Provision of personal protection equipment to 44

hospitalshospitals9.9. Insurance protection for health personnel in high riskInsurance protection for health personnel in high risk10.10. National, regional & international coordinationNational, regional & international coordination

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Health Health -- Main Difficulties FacedMain Difficulties Faced

1.1. Limited laboratory equipment and hospital Limited laboratory equipment and hospital supplies supplies

2.2. Inadequate stockpiling of oseltamivir in 44 Inadequate stockpiling of oseltamivir in 44 hospitalshospitals

3.3. Weak surveillance and reporting from district levelWeak surveillance and reporting from district level4.4. Need training surveillance and case management Need training surveillance and case management

for medical doctors in health center and hospitalsfor medical doctors in health center and hospitals5.5. Research and development to improve Research and development to improve

understanding of H5N1understanding of H5N16.6. Risk Communication to the publicRisk Communication to the public

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Current support fromCurrent support fromInternational communityInternational community

WHO and FAO: development of AI preparednessWHO and FAO: development of AI preparednessSupports and commitment from WB, GTZ, Japan, Supports and commitment from WB, GTZ, Japan, Australia, Netherlands, US, Australia, and Korea and Australia, Netherlands, US, Australia, and Korea and others for technical assistance, equipment, training, others for technical assistance, equipment, training, workshop, isolate testing, etcworkshop, isolate testing, etc

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Need for Better Coordination and Partnership:Need for Better Coordination and Partnership:

Coordinated secretariat/task force to ensure concerted all-of-government response

( among/between government agencies at central and different level of government national-provincial-local)

1. Emphasize the need for:a comprehensive control strategy in support of common objectives of national preparednesscoordinated supports of multilateral, bilateral donors, and international agencies (donor coordination)increased support to health and agricultureeconomic analysis of the likely overall costs of the failure to control avian influenza

2. Government update; exchange of information; identification of steps to be taken

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NEXT STEPSNEXT STEPS

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COMMON OBJECTIVES:Prevent the AI phase from entering the next phase of pandemicTreatment and care for victims (human and animals)Minimize losses of AI impactSustainable management of AI – keep at minimum and manageable level.

CURRENT PLANS IN PLACENational Influenza Pandemic Preparedness Plan (NIPPP) Ministry of HealthNational Strategic Plan For AI Control in Indonesia 2006 – 2008 Ministry of Agriculture

INTEGRATED NATIONAL PREPAREDNESSWill combine 2 core plans – with other line ministries related and coordination of national and local government program and activities and aligned with government budgetWe are optimist with the readiness and we will listen, observe and take serious note of the recommendation from this meeting.We welcome and encourage participation and help from international communities with a strong request to be willing to be coordinated (among donors) and between donors and GOI/line ministries.

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STEPS TOWARDS INTEGRATIONSTEPS TOWARDS INTEGRATIONHEALTH:

AI Preparedness

COMMON OBJECTIVES:

• Prevent the AI phase from entering into the next phase

• Treatment and care for victims (human and animals)

• Minimize losses of AI impact• Sustainable management of AI

NATIONAL SYSTEMON AI

PREPAREDNESS

AGRICULTUREAI Preparedness

ENVIRONMENTAL CONTROL:Wild animals

Domestic animalsQuarantine

NeighborhoodOpen Spaces

Social EconomicConsumption,

Trade,Economic

- All relevant ministries- National – local gov.coordination

2020

ACTIVITIES IN NEED OF SUPPORT

Strengthen Surveillance Systems for animals and Strengthen Surveillance Systems for animals and humanshumans

Capacity building for improved case identification Capacity building for improved case identification (training for veterinarians, health personnel)(training for veterinarians, health personnel)Provision of Laboratory Equipment & Additional Provision of Laboratory Equipment & Additional substancessubstancesOperational cost in infected areas (drugs, vaccine, Operational cost in infected areas (drugs, vaccine, investigation)investigation)

Increase Understanding of the EpidemicIncrease Understanding of the EpidemicBioBio--molecular epidemiology of AI virusmolecular epidemiology of AI virus

Assessment of Efficacy of Control MeasuresAssessment of Efficacy of Control MeasuresStudy on progressive establishment of diseaseStudy on progressive establishment of disease--free free compartmentscompartmentsStudy on effectiveness of cullingStudy on effectiveness of cullingStudy on the effectiveness of AI vaccination in poultryStudy on the effectiveness of AI vaccination in poultry

Public Awareness and Risk Communication Public Awareness and Risk Communication StrategyStrategy

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Estimated Funding required (MOH)Estimated Funding required (MOH)

Cost (US$ million)

Total (US$ million)

A. Preparedness & response 13.15- Planning and Coordination 1.18

- Surveillance 1.67

- Prevention and control 0.98

- Health system response 8.70

- Risk Communication 0.62

B. Contingency Phase 4 (home treatment, hospitalization, burying corpses)*

499.13

*Notes : Contingency plan will be designed when Indonesia is entering phase 4 of WHO Pandemic Phase. More epidemiological data on avian flu have to be collected and analyzed accordingly

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Estimated Funding required (MOA)Estimated Funding required (MOA)STRATEGY Total

(US$ million)

Capacity building 16.5

Zoning and compartmentalization 1.8

Restructuring poultry system 1.9

TOTAL 138.2

Strengthening regulation and institution 6.2

Improvement of coordination and cooperation 2.4

Increase private sector involvement 4.8

Disease control and rapid response 88.0

Research and Development 16.6

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Thank You