Proc ASEAN Congr Trop Med Parasitol. 2008;3:38-42.

Available online at www.ptat.thaigov.net

Epidemiology of Avian Influenza in Indonesia.

Why is West Java
Having the Highest Endemicity?

Ridad Agoes1, Sadeli Masria2

Graduate School of Public Health, Padjadjaran University

1

2
Department of Microbiology, Faculty of Medicine, Padjadjaran University

Abstract

F rom December 2003, outbreaks of highly pathogenic avian influenza were reported in poultry populations
in Indonesia and beyond. Within Southeast Asia and the wider Asian region, outbreaks have been
reported in at least 15 countries, including Cambodia, China, Indonesia, Japan, the Republic of Korea, the
Lao PDR, Myanmar, Malaysia, Thailand, and Vietnam. The strain, identified as H5N1, has led to massive
die-offs in bird, chicken, and duck populations. In Indonesia, > 90 million poultry were either culled or died.
Within these countries, the disease has also infected a significant number of people. To date, 235 human
cases of avian influenza H5N1 have been detected in several countries, including Indonesia. Of this number,
105 casualties (44.7%) were reported from Indonesia alone. The majority of human cases have resulted
from direct contact between humans and infected poultry or contaminated environments. In a few instances,
limited human-to-human transmission of the virus could not be ruled out. Despite this, there have been no
large clusters of human cases, indicating that the virus has not yet adapted for widespread human-to-human
transmission; however, the high prevalence and different mortality rates within the region require more intense
study. Among the 29 provinces of Indonesia, 12 have reported human fatalities, with West Java holding the
highest case fatality rate (CFR–25 deaths from 31 infections. This paper discusses the factors causing West
Java Province to have the highest mortality rates in the country. With the global spread of the virus and its
pandemic potential, measures should be found to respond to outbreaks, including enhanced surveillance,
outbreak management, and hospital preparedness.

Keywords: human avian influenza, West Java, high prevalence

Background resurfaced in Thailand, Indonesia, Cambodia, China,

Avian influenza, or bird flu, is a zoonotic poultry
disease caused by a subtype of the H5N1 virus, which
primarily affects domestic poultry and wild birds.
The virus first appeared in Hong Kong, in 1997, and
Correspondence:
Ridad Agoes,
E-mail: <ridadagoes@yahoo.com>
Japan, Lao PDR, South Korea, and Vietnam, in late
2003-early 2004 (source: Centers for Disease Control
and Prevention). By 2007, the disease had reportedly
spread to 13 countries.
The year 2007 marked a watershed in terms of
human fatalities. Indonesia was the worst-affected
country, with over 124 cases and 100 documented
human deaths, followed by Vietnam. One real fear,

38 P r o c o f t h e 3 rd A S E A N C o n g r o f Tr o p M e d a n d P a r a s i t o l . P a r a s i t e s : a H i d d e n T h r e a t t o G l o b a l H e a l t h
 Epidemiology of Avian Influenza in Indonesia. Why is West Java Having the Highest Endemicity?
Map of Indonesia
Table 1 Current H5N1 avian influenza situation;
human cases in Asia.
Countries Confirmed Confirmed
cases deaths
Indonesia 129 105
Vietnam 104 50
China 29 19
Thailand 25 17
Total (14) 366 232
Table 2 AI Mortality in Indonesia.
Year Confirmed Confirmed CFR (%)
cases deaths
2005 20 13 65
2006 55 45 81
2007 42 37 88
2008 16 13 81
Total 133 108 81
according to scientists, is that if the H5N1 virus mutates
into a form that transmits easily between humans, a
horrific flu pandemic could result and claim millions of
lives, since there is as yet no reliable treatment for the
disease.
Bird flu has emerged as a potentially lethal threat
to humans in the 21st century. Between 2003 and end
April 2008, the deadly H5N1 virus had claimed over
216 lives globally from 349 confirmed cases (source:
WHO).
As of March 2008, human cases of avian influenza
have been found in at least 13 of 33 Indonesian
provinces (North Sumatra, Riau, South Sumatra,
Lampung, Banten, Greater Jakarta, West Java, Central
Java, East Java, South Sulawesi, and West Sulawesi),
with 124 confirmed cases and 100 deaths. The CFR, at
around 87.5%, is higher than other Asian countries.
Infected poultry flocks have been found in 27
of Indonesia’s 33 provinces. Domestic ducks, which
are common in many parts of Indonesia, including
Java and Bali, can excrete large quantities of highly
pathogenic viruses without any visible signs of illness.
Their silent role in maintaining transmission further
complicates control in poultry and makes human
avoidance of risky behaviors more difficult.
AI case clusters have been found in 8 events; the
largest was in Karo District, North Sumatra, where 7
of 9 cases died. Poultry and pigs have been identified
as possible vectors. Several experts, and the WHO,
suspect limited human-to-human transmission, due to
the finding of adapted H5N1 virus receptor 2.6, which
has the potential for human-to-human transmission.
The National Commission for Avian Influenza
Pandemic Preparedness and Control, at the
Coordinating Ministry of Social Welfare, Indonesia,
has issued The National Strategic Plan on Avian
Flu Control and Influenza Pandemic Preparedness;
however, the actual implementation of the strategy in
provinces/districts/cities is still needed.
39
 Epidemiology of Avian Influenza in Indonesia. Why is West Java Having the Highest Endemicity?
The National Strategic Plan on Avian Flu Control
and Influenza Pandemic Preparedness 2006-2008
includes 10 components:
1. Highly pathogenic avian influenza control in
animals;
2. Management of human cases of AI;
3. Protection of high risk groups;
4. Epidemiological surveillance on animals and
humans;
5. Restructuring the poultry industry system;
6. Risk communication, information, education
and public awareness;
7. Strengthening supporting laws;
8. Capacity building;
9. Operational research; and
10. Monitoring and evaluation.
The National Institute of Health Research and
Development (NIHRD) has become the central public-
health laboratory for avian influenza in Indonesia, with
links to the laboratories of the Eijkman Institute and
NAMRU Laboratory in Jakarta, WHO-CC Reference
Laboratories, and the Centers for Disease Control in
the USA.
In anticipation of a large epidemic, and to build
awareness among communities all over Indonesia, the
NIHRD has initiated several strategic activities:
• Estimating the potential health and macro-
economic impact of a large avian-influenza
epidemic in Indonesia;
• Thorough investigation of sporadic human
cases and clusters of cases, to determine the
potential for human-to-human transmission
• Developing operational research for
controlling avian influenza epidemics in the
community;
• Developing and operationalizing a pandemic
response model, and rehearsing the pandemic
response plan.
Community and social study
Indonesia is a vast, culturally diverse, country. To
date, almost 4 years after the AI epidemic began in
poultry, only a few social and behavioral studies have
been conducted. These studies have mainly been
limited the populations’ knowledge and attitudes (KAP)
towards AI.
40
Two successive studies by UNICEF, in 2007,
measured levels of public awareness and the impact
of media campaigns. Preliminary findings indicated
that, although AI awareness among the population
was high (almost 100%), perceived knowledge was
very low (~30%). Only 5% thought their family or
neighborhood might be affected. Concerns and worry
levels were fairly high (49 & 56%, respectively) vs 39%
the previous year, but there was little sense of urgency.
AI was seen as something “distant, which will not affect
the immediate family”.
The survey results showed that:
• People were more open to talking about AI
than in 2006 (50% vs 37%);
• Awareness of avoiding poultry seemed higher,
as the number of people who stopped raising
poultry rose (26% vs 15%);
• Concern over poultry that die suddenly did
exist, but handling practices were largely
incorrect (about 80% disposed of dead birds
incorrectly);
• Bans on raising backyard poultry were
generally accepted. Objections normally
came from poultry owners for economic
reasons;
• Regulations to keep poultry away from houses
were generally accepted. Objections were
mainly due to security concerns (fear of
theft).
A survey by USAID provided more information on
AI-related KAP:
Regarding exposure to poultry raising, it was
mainly the parents who decided to raise poultry, and
they were mostly assisted by their adult children.
Younger children had limited involvement in poultry
rearing, but they did play with the poultry, especially
the boys.
• Poultry were set free during the day and
caged at night. This was the dominant mode
of poultry-raising in almost all areas.
• Those who did not cage their poultry, said
they did so because the poultry had to find
their own food;
• Handwashing was a routine practice after
handling poultry – mostly with soap and
water;
 Epidemiology of Avian Influenza in Indonesia. Why is West Java Having the Highest Endemicity?
• Clothes were not regularly changed after
handling poultry, because it was considered
unnecessary or felt that the clothes were still
clean;
• The use of personal protection was not
common. For those using protection, gloves
and masks were the most common.
• When questioned about Flu Burung (Bird
Flu), the majority had heard of the name, but
were not well informed about its signs and
symptoms;
• AI was associated with death: it killed poultry
immediately;
• People regarded AI as a new disease, the
perceived difference between AI and other
diseases being that it kills faster and more
often.
Major issues and bottlenecks regarding public
awareness and healthy behavior:
• The level of knowledge was inadequate – and
still needs to be translated into changed
behavior;
• There was no wider understanding of why AI
prevention is so important, eg, “there are so
many other diseases that have killed many
more people”. Why bother about AI?
• Policy enforcement: people agreed to a
ban on backyard poultry, but lacked the
willingness and financial means to do it
themselves. They waited until the government
enforced the rule.
• A wide variety of styles, approaches,
campaign themes and the sheer number of
Public Service Announcements itself could
potentially confuse the public, reduce media
buying efficiency, overall awareness, and lead
to less impact;
• There is an urgent need to develop a joint
campaign in order to maximize impact.
The proposed “National Baseline Health
Research”, to be conducted August-September 2007,
will also collect data on the knowledge of people about
AI all over Indonesia. This knowledge is insufficient to
design effective interventions for AI intervention and
control. A systematic social and behavioral study,
aimed at reducing human exposure to poultry, has not
yet been conducted. Such a study would encompass
AI-preventive behaviors, treatment-seeking behaviors
and health-service utilization, as well as compliance
behaviors to proposed AI prevention and control
measures. Without an in-depth understanding of
AI-related behaviors and their underlying factors,
communication for behavioral change and other
interventions are less likely to gain active community
participation, which is key to the success of any
disease prevention and control program, including
AI.
The Phase one study will explore existing
AI-related behaviors, then analyze in-depth socio-
cultural factors that may promote AI risk behaviors,
or hinder AI preventive and prompt treatment seeking
behaviors, and compliance with AI control measures
and recommendations. The role of local and traditional
media in inducing AI-related behavioral change will be
studied.
The knowledge gained from the Phase-one study
will be utilized in designing social interventions for
behavioral change, which will be followed by Phase
two.
Conclusions and recommendations
West Java has the highest incidence and
prevalence of human cases of AI. This situation will
persist for the near future, since steps to control its
spread have been met with ignorance and resistance.
The West Java Government has not raised sufficient
public awareness of the serious danger. It is quite
possible that a highly pathogenic mutant AI virus will
arise in West Java, where the next pandemic may
possibly start.
Community behaviors related to poultry in all West
Java villages is directly related to an elevated risk of
AI. A large proportion of the community perceives no
danger from AI.
Community-based health education and or
counseling which involves public figures are necessary,
because most of the risk behavior is related to tradition
and culture.
Community education must be made the highest
priority, and should be directed to safeguarding
both poultry farming and human health, through a
strategy that includes advocacy at different levels and
41
 Epidemiology of Avian Influenza in Indonesia. Why is West Java Having the Highest Endemicity?
with different stakeholders, social mobilization, and
behavior change/behavior development strategies.
Communication and planned processes for social
change should implement several strategies with
different social strata.
Motivational messages should include the
following elements: proper hygiene practices; safe
handling of chickens, ducks and birds; reporting sick
or dead chickens, ducks and birds; high risk of the
surrounding environment; proper disposal of chicken,
duck and bird droppings; how to get support for
separating chickens, ducks, and birds from humans;
promotion of correct cooking of chickens and eggs.
Simple steps with high efficacy levels, already
suggested by the CDC are promoting hand-washing
with soap and water, correct handling of poultry, and
cooking eggs and poultry meat thoroughly.
An AI vaccine will remain the ultimate long-term
solution. Indonesia is currently developing the capacity
to learn appropriate technologies to produce such a
vaccine.
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