Indonesia Situation Update

WHO Indonesia June 2006

World Health Organization

Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO globally (as of 29 May 2006)
Country 2003 2004 2005 2006 Total

cases
Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey Viet Nam Total 0 0 0 0 0 0 0 0 0 3 3

deaths
0 0 0 0 0 0 0 0 0 3 3 0 0 0 0 0 0 0

cases

deaths
0 0 0 0 0 0 0 12 0 20 32 0 4 8 0 0

cases

deaths
0 4 5 0 0 11 0 2 0 19 41 8 2

cases

deaths
5 2 7 0 6 25 2 0 4 0 51 8 6

cases

deaths
5 6 12 0 6 36 2 14 4 42 127

10 1 14 31 2 0 12 0 80

18 1 14 48 2 22 12 93 224

17 0 5 0 61 95

17 0 29 46

World Health Organization

Animal Outbreaks & Human Cases, Indonesia (as of 29/5/06)

World Health Organization

Human Cases H5N1, Location

(as of 29/5/06)

World Health Organization

Cases
10 11 0 1 2 3 4 5 6 7 8 9

07/03/2005 17/7/2005 31/7/2005 14/8/2005 28/8/2005 09/11/2005 25/09/2005 10/09/2005 23/10/2005 11/06/2005 20/11/2005 12/04/2005 18/12/2005 01/01/2006 15/1/2006 29/1/2006 02/12/2006 26/2/2006 03/12/2006 26/3/2006 04/09/2006 23/4/2006 05/07/2006 21/5/2006
Pending Recover Fatal Week Ending

Epidemic Curve (as of 29/5/06) Human Confirmed Cases H5N1, Indonesia by week

World Health Organization

Epidemic Curve (as of 29/5/06) by month

16 14 12 10

Cases

8 6 4 2 0

Recover Fatal

r m be

r N ov em be r D ec em be r Ja nu ar i Fe br ua ry

ug us

Ju li

il pr A

ob e

ar c

ep te

O ct

Month

World Health Organization

ay

Cases by urban/rural
Environmental Setting

14 29%

13 27%

Semiurban

Urban
Urban setting Rural setting Semi-urban setting

Rural

21 44%

World Health Organization

Cases by age group and sex

35 to 45 30 to 34 25 to 29

Age

20 to 24 15 to 19 10 to 14 5 to 9 0 to 4 -8 -6 -4 -2 Male 0 | 2 Female 4 6 8

Male Female

World Health Organization

Cases by occupation
Uncertain 6 12% Agricultural Farmer 1 2%

Child 11 22% Child Student Poultry Worker / Breeder Wet Market Worker HCW Non-farm Occupation Agricultural Farmer Uncertain

Non-farm Occupation 14 30% HCW 1 2% Wet Market Worker 2 4%

Student 10 20% Poultry Worker / Breeder 4 8%

World Health Organization

Likely Source of Exposure

12 25% 11 23%

Pending

Direct
Direct Exposure Indirect Exposure Fertiliser Inconclusive Pending

Inconclusive
6 13%

Indirect

2 4%

17 35%

World Health Organization

Case Profiles (as of 29/5/06)

48 cases / 36 fatal (CFR: 75%) Mean age: 20 years (range 1.5 43 years) Median age: 19 years Male to female ratio 1.3 : 1 Cases:
Rural = 21 Semi-urban = 14 Urban = 13
World Health Organization

Duration of Illness (fatal cases, n= 36)

12

10

Duration (Days)

0 Jul-Sep 05 Sep-Dec 05 Jan-Mar 06 Apr-Jun 06 Yearly Quarter

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Clusters in Indonesia
Cluster Cases Fatal Source H2H Type of cluster

1 2
3

3 (1 confirmed, 1 pending, 1 suspect) 2 (2 confirmed)

3 (3 confirmed)

3 1
0

Inconclusive Fertilizer
Direct (sick chicken)

Cannot be ruled Blood-related out family Cannot be ruled Blood-related out family
Unlikely Blood-related family

2 (2 confirmed)

Exposure (sick chicken)

Direct (sick chicken)

Unlikely

Blood-related family
Blood-related family

4 (2 confirmed, 2 suspect)

Unlikely

8 (7 confirmed, 1 suspect)

Pending

Cannot be ruled Blood-related out family

World Health Organization

Serious problems
This is still a very rare disease in humans.
Low recognition of risk.
General public re: poultry biosecurity, etc.

Low index of suspicion when it occurs.

General public and medical practitioners re: diagnosis and early treatment

World Health Organization

Serious problems
52% (25) of human cases are sentinel cases for a poultry outbreak in progress.
No reporting, no response to poultry outbreak
Birds die all the time, no sense of urgency.

No credible response mechanism to cleanup poultry outbreaks.

Compensation. Culling / disposal.
World Health Organization

Serious problems
No communication of the risk profile: dead/dying poultry
Children and students Ordinary public keeping birds in the backyard. No wide communication and recognition when poultry deaths move through a community, neighborhood by neighborhood.

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Serious problems
Late recognition of signs and symptoms in humans:
Many early cases resemble dengue, typhoid, or influenza-like illness (without complications). Most cases visit several health care providers, including traditional healers, before finally being hospitalised (when first clear signs of complication are seen). No clear history of risk exposure to poultry. No rapid bedside lab tests.
World Health Organization

Days Between Onset-Hospitalization-Death

48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1

Case No

Days between Onset-Hospitalization Days between Hospitalization-Death

10

12

14

16

18

20

Days Health Organization World

Cases (n=8) by date of onset, Karo district, Sumatra April-May 2006

Number of cases
MOH/WHO team in Medan to interview survivors and family Medan Provincial Health Office notifies MOH, MOH notifies WHO

Lab confirmation of 5 cases Interviews Kabenjahe, local investigation Kubu

Village investigation

5 cases diagnosed at KJ hospital, referred to Medan

Rule out of HCW and family member

1 22 23 24 25 26 27 28 29 30 1 April alive died

3 2 3

5 4 4

7 6 5

8 9 10 11 12 13 14 15 16 17 18 May

lab-confirmed
World Health Organization

Serious problems
Decentralisation
Lack of chain of command. Lack of authority.

Inadequate budget allocations. Lack of political will?

Long time line for action.

World Health Organization

Thank You

World Health Organization

Acknowledgements
Investigation Teams Health/Ag Officials Lab Workers Hospitals Consultants

World Health Organization

Observations

Over 500 cases have been investigated: most excluded (lab-based) Time between onset and notification = 5 days Time between notification and lab results: available within 3 days for 70% of cases Majority of cases detected in urban/peri-urban Jakarta
Better notification/surveillance? Overlap of high density of human and poultry populations?

Hypothetical transmission models: psittacosis?

World Health Organization

Recent Studies in Indonesia

Serosurveys: over 2000 people tested, only 1 poultry worker positive Sentinel human influenza surveillance (NAMRU): no H5 identified through the 20 sentinel health center / hospital sites Bali Study: 940 human blood samples collected from households in all 9 districts and 3 wet markets in Bali (all AI affected areas). Chicken, duck and pig samples

also collected (3000 samples)

30% households had chicken deaths 130 poultry workers (close contact with birds) NIL HUMANS POSITIVE Only 7 ducks/1 chicken H5N1 positive in 2 wet markets Data suggest that virus circulating in market places but not in the communities, the disease remains a rare-event in humans despite widespread disease in birds
World Health Organization

Lessons Learnt
Virus not yet adapted to human transmission
All isolates both avian and human remain within a single clade which can be dated back to August 2003 introduction. No evidence of reassortment or significant mutation til now.

Data collection/sampling difficult outside Jakarta (eg viral transport media, Tamiflu stocks)
Continued procurement, distribution and training.

Need better data-sharing between human health & animal health labs/public health units
Institutional and other barriers remain to be overcome.

Communication between the authorities and the local government critical

Evidence for local implementation of culling and vaccination needs to be supported.

World Health Organization

Lessons Learnt
Rumor verification:
Aggressive news/media environment. Culture of SMS reporting and response. Community demand (decentralisation)

World Health Organization

Are we finding / missing cases?

All notified suspect cases (500+) are investigated.
17 provinces with suspected case referrals.

Zero-reporting practiced by 44 referral hospitals. All cases with lab-evidence are investigated in the field, search for additional cases among family, neighbors and other contacts.
Inteviews, swab samples, serum samples. 4 of 6 clusters found through field investigation.

NAMRU influenza sentinel system:

200-300 swab samples per month from symptomatic ILI patients presenting at 20 health centers across Indonesia. Nil positive for H5.
World Health Organization

If cases are missed

Cases reported
50 50 50 50

% underreporting 10%
50% 90% 99%

Estimated no. of cases 55

50 500 5000

World Health Organization

National Strategies
Strategy Avian Influenza Control in Animals Management of Human Cases of AI Tamiflu,ventilators,guidelines WHO Examples of Activities

Protection of High-Risk Groups

Epi Surveillance: Animals & Humans Restructuring Poultry Industry System

Healthy markets, PPE

OR, Village surv system Posters, booklets, media spots, coord. with partners Training, lab and hospital facilities

Communication, Information, Awareness

Strengthening Supporting Laws Capacity Building

Action Research
Monitoring and Evaluation
World Health Organization

Bali, support donor projects

Database,analysis,ext.review

National Response Strategy

Developed in December 2005 based on MoH & MoAg plans/input Intersectoral strategy that includes:
Control of avian influenza Preparedness for pandemic influenza

World Health Organization

NATIONAL COMMITTEE ON AVIAN INFLUENZA CONTROL - KOMNAS

CHAIRMAN

Operation Officer

Communication and Public Information Sub-group

Secretariat

Planning

Budget

International Cooperation

Vaccine and Anti-Viral Group

AI in Animal Group

AI in Human Control Group

Research and Development Group

Provincial AI Control Committee

District AI Control Committee

World Health Organization

MoAg / FAO
Strategic Work Plan developed in Dec 2005.
Surveillance Selective culling Vaccination

World Health Organization

MoAg / FAO: Community based Early warning to AI

National Disease Command Center (NDCC) Local Disease Coordination Centers (LDCC)
4 pilot areas (Bandung, Malang, Bogor, Jogjakarta)

Participatory Disease Surveillance (PSD)

12 pilot districts, 3 per LDCC

Participatory Disease Response (PDR)

8 teams operating from LDCCs

Community-based solutions to:

Housing/fencing of poultry Disposal of dead birds Village bio-security
World Health Organization

Progress
Increased political commitment to AI Increased donor/NGO interest and participation Various projects are underway:
Preliminary results from the Bali study Tangerang Municipality Pilot Project: preparation phase Provincial authorities are increasingly asking for assistance and guidance in preparing local plans MoH is working on SOP for containment strategy, revision of surveillance and case management guidelines as well as rolling out guidelines for health centers on the management of suspected cases of AI.
World Health Organization

Last Revised

AI Cluster Outbreak, Kubu Simbelang, May 2006

55yo F J Mother of Index +4 sibs No illness/Live House 1

25 May 2006

House 1 / Index

House 2
29yo F ABS Onset: 5/5 Died: 10/5 PCR+

House 3

House 4 (Different
Village)

37yo F PBG Onset: 24/4 Died: 4/5

??yo M Er No illness

32yo M D Onset: 15/5 Died: 22/5 PCR+

25yo M JG Onset: 4/5 Survivor PCR+

18yo Son RKK Onset: 4/5 Died: 9/5 PCR+

32yo Husband H No illness

21yo Daughter F No illness Living House 1

29yo Wife B No illness

??yo Wife Am No illness

17yo Son BKK Onset: 5/5 Died: 12/5 PCR+

1-1/2yo Daughter BbT Onset: 3/5 Died: 14/5 PCR+

2?yo Fiance I No illness

10yo Son RG Onset: 3/5 Died: 13/5 PCR+

3yo Son P No illness

10yo Son A No illness

10yo Son C No illness

6yo Son No illness

5mo Son P No illness

Legend :
6yo Daughter M No illness

Blue = male

Peach= female Vert.stripe = death Horiz.stripe = survivor

Solid = No illness

World Health Organization

ORGANIZATIONAL STRUCTURE MINISTRY OF HEALTH REPUBLIC OF INDONESIA

Dr. Siti Fadilah Supari Minister of Health

Dr. Syafii Ahmad Secretary General

Dr. Krishnajaya Inspector General

Dr. Sri Astuti S. DG Comm Health

Dr. Farid Wadji Husain DG. Med Care

Drs. HM Krissna T. DG. Pharm & Health Fac.

Dr. I Nyoman Kandun DG. CDC & EH

Dr. Muharso Head of PPSDM

Dr. . Head of NIHRD

Dr. Bambang Hartono Ses.Dit.Gen

Dr. Rustam S Pakaya Ses.Dit.Gen

Dra. Nasirah B Ses.Dit.Gen

Dr. Indriyono Tantoro Ses.Dit.Gen

Drs. Zulkarnain Kasim Secretary PPSDM

Drg. Titte Kabul Secretary NIHRD

Dr. Sri Hermiyanti Dit. Family Health

Dr. Ratna Rosita Dit. Med Care & Basic Dental Care

Drs. Abdul Muchid Dit. Comm Pharm. & Clinic

Dr. Rosmini Day Dit. Direct CDC & EH

Dr. Triono Sundoro Chief Pusdiklat

Dr. Suwandi Makmur Chief, Center for Health Service & Personnel

Dr. Wandaningsih Dit. Komunitas

Dr. Dit. Med Care & Specialistic Dental Care

Dr. Husniah Rubiana Dit. Rational Use Of Drugs

DR.Dr.Hariadi Wibisono Dit. Vector Borne DC

Dr. Setiawan Soeparan Chief Pusdiknakes

Dr. Erna Tresnaningsih Chief, Research Dev. On CDC

Dr. Pandu Setiawan Dit. Mental Health

Drg. Haerawan Dit. Nursing & Technical Medic

Drs. Bahron Arifin Dit. Public Drugs & Health Supply

Dr. Yusharmen Harun Dit. Epid. Surveillance & Matra Health

Dr. Untung Suseno Chief Pusgunakes

Dr. Faizati Karim Chief, Research Dev On Health Ecology

Dr. Rachmi Untoro Dit. Nutrition

Ir. Tugiyono Dit. Medical Facilities & Equipment

Drs. Tato Suprapto Dit. Prod & Distrib. Of Med Devices

Dr. Wan Alkadri Dit. Env. Health

Dr. Asjikin Iman Hidayat Chief Empowerment of Health Manpower

Dra. Nani Sukasediati Chief, Center for Pharm. & Traditional Drugs

Drs. Ida Bagus Indra G Dit JPKM

Dr. Yulizar Darwis Dit. Health Laboratory

Dr. Achmad Hardiman Dit. NCDC World Health Organization

Mr. Soenarno Ranu W Chief, Center for Nutrition & Food