Public Health Policy & Clusters of Avian Influenza A H5N1 in

Indonesia

Dr I Nyoman Kandun

Background

Indonesia: Human Population

• Indonesia population: 228,000,000

• 17,000 islands, densely populated (116 persons per sq. km)

• 33 provinces, 480 districts

• Decentralization: district level

Indonesia: Birds

• Birds in Indonesia have an important significance:

– Source of animal protein – many households (despite SE status) keep chickens

– Source of entertainment (singing birds, cock-fighting, pets)

– Income generating (sold in markets, bartered)– Role in mythology (Garuda bird – national

symbol)

H5N1 situation in humans

• Geographic Distribution:• 12 provinces out of 33 have confirmed AI cases, where

47 districts from 484 have reported human cases. • However, in the last 6 months, only 5 of the 12 affected

provinces reported cases.

• Demographics• Mean age of cases is 20 yrs, Range is 18 mths to 67 yrs. • The male to female case ratio is 1:1. • Rural (44%), Urban (29%) and Semi-Urban (27%)

Epicurve of H5N1 Cases

• Overall 81% case fatality rate: high.

• Epicurve indicates ongoing exposure of humans to virus in Indonesia.

0

2

4

6

8

10

12

14

16

18

Month

Ca

se

s

Recover

Fatal

Case Occupation

Occupational exposure = 11% of cases

44% cases are young: reflect underlying population trends

Exposure risk factors

Public health sector

Clusters in Indonesia

Clusters

• Indonesia cluster definition: two or more epi-linked cases where at least two are laboratory-confirmed H5N1.

• Indonesia observed 11 clusters meeting this definition.

• Cluster size: – Median: 3 people/cluster– Range: 2 - 8 people per cluster

Common Findings from Clusters

Cluster #

Cases Fatal Mode of Transmission

H2H Type of cluster

1 3 (2 confirmed, 1 suspect)

3 Unknown Cannot be ruled out

Blood-related family

2 2 (2 confirmed) 1 Fertilizer Cannot be ruled out

Blood-related family

3 3 (3 confirmed) 0 Direct (sick chicken)

Unlikely Blood-related family

4 2 (2 confirmed) 1 Exposure (sick chicken)

Unlikely Blood-related family

5 4 (2 confirmed, 2 suspect)

2 Direct (sick chicken)

Unlikely Blood-related family

Cluster Findings

• Survival was better in clustered cases than sporadic cases (OR 33.3, CI 3.13-273)

• Secondary cases in clusters received tamiflu earlier than index cases (5 vs. 8 days, p=0.04)

Sociological and Anthropological Aspects

Two Aspects

• Factors leading to human infection– Cultural practices associated with birds– These are factors that need to be understood to enable

disease prevention activities

• Factors affecting outbreak investigation and immediate disease control activities– Cooperation of affected community– Issues of stigma and role of media– These factors need to be understood to enable

appropriate disease control measures to prevent further spread

Example of Factors Leading To Infection

“Live chickens were purchased from an outside market in preparation for a religious feast and were integrated into local flocks. Shortly thereafter, chickens began dying in large numbers in an outbreak that continued throughout July and the first week of August, gradually spreading from one hamlet to another. These exposures are, at present, thought to be the source of infection for most confirmed cases.”

Example of Factors For Disease Control

• A cluster of 8 cases (7 confirmed, 1 suspect) occurred in North Sumatera in April-May 2006.

• The index case was most likely infected through contact with sick household chickens or through poultry contact at her workplace - a local wet market.

• Public health personnel experienced difficulty in engaging the cooperation of the family during the investigation. Factors included:

– Stigma associated with the outbreak: claims that chickens in the community were healthy

– Family disbelief that patients were infected with AI: govt conspiracy– Anger & bereavement at loss of family members– Perception that hospital is where people go to die

Example

Lessons Learnt from Cluster

• Initial failure of risk communication triggered community resistance to public health activities

• Journalists have a role in reporting: Public health officials need to inform journalists about situation and encourage non-inflammatory reporting that may upset community

Analysis of Anthropological & Sociological Aspects

• Outbreak investigations and social research have helped us in responding to AI in Indonesia.

• Public health education campaigns are ongoing in Indonesia to educate the public about AI and the importance of health seeking behavior (preventive and curative)

• Behavioral sciences play an important role in disease control. This recognition is a positive step in public health practice.

AI Public Health Policy

National Response Strategy

• Developed based on MoH & MoAg plans/input

• Intersectoral strategy that includes:– Control of avian influenza – Preparedness for pandemic influenza– Capacity building for future public health

threats

National Strategies

Strategy MOH

Avian Influenza Control in Animals

Management of Human Cases of AI

Protection of High-Risk Groups

Epi Surveillance on Animals & Humans

Restructuring the Poultry Industry System

Risk Communication, Information & Public Awareness

Strengthening Supporting Laws

Capacity Building

Action Research

Monitoring and Evaluation

Response Perspectives

Ministry of Health– Prevent human

cases of avian influenza

– Minimize risk of pandemic influenza

Ministry of Agriculture– Prevent economic

loss for farmers– Control spread of

disease

To achieve both objectives, the aim is to reduce the virus circulating in the

environment.

AI Public Health Activities

• Disease surveillance:– Early detection: DSO & PDSR joint activities– Training of primary healthcare workers – Hospital-based pneumonia surveillance

• Case management:– Providing supplies, infection control training,

improving ARDS management

• Risk communication:– Community PSAs, village-mobilization, education

programs through primary health care workers

Activities: long term benefits

1. Re-vitalization of the FETP in Indonesia.

2. Strengthening rumor surveillance: EWARS

3. Regulation and improvement of the food markets using WHO’s Healthy Food Market strategy.

4. Revision of the national infection control (IC) guidelines & roll-out to hospital IC teams.

5. Provision of & training in use of essential HCF equipment:– Ventilators– Portable x-ray machines

STAR ANISE

THANK YOU FOR YOUR ATTENTION