Bird Flu In Indonesia: Prevalence, Mortality, And Action

In order to help Indonesia improve its high human mortality due to bird
flu (H5N1 influenza), more effective diagnostic methods must be used
and improved case management must be implemented to achieve faster
treatment with antivirals, according to the authors of an article
released on August 14, 2008 in The Lancet.



Most of us are familiar with the flu, which seasonally affects many
populations. Because it is an RNA virus, it will undergo genetic shifts
relatively rapidly, providing challenges for scientists in creating
vaccines. Avian influenza, also known as bird flu or H5N1 has achieved
notoriety recently as it has transmitted from birds to humans with
often fatal outcomes.



Internationally, the most human cases of bird flu have been found in
Indonesia, which also has one of the highest case-fatality rates. While
surveillance systems have been implemented to increase awareness to
potential outbreaks, there are still significant risk factors that
exist in this country.



To investigate the factors that contribute to the fatality of bird flu
in Indonesia, Dr Toni Wandra, Directorate General of Disease Control
and Environmental Health, Ministry of Health, Jakarta, and colleagues
analyzed all 127 bird flu cases manifesting between June 2005 and
February 2008. Each case was investigated by teams for epidemiological
and clinical data from both case investigation reports and interviews
with patients, family members and other individuals associated with the
case.



In the first two days after onset, most patients had non-specific
symptoms.В That is, of the 122 patients with complete data, 25%
had both fever and cough, and 7% had fever with breathing problems. The
symptoms upon reaching the hospital were as follows: 99% had fever (121
cases), 88% had cough (107 cases), and 84% (103 cases) had breathing
problems.



The median time from onset to treatment with oseltamivir was seven
days. Survival frequency when compared to treatment time, the following
was found, indicating a significant difference in treatment outcome
between treatment in two days or less and five days or more:


The one patient who received treatment within 2 days
survived.
Of patients receiving treatment within 2-4 days, 36% (4 of
11) survived.
Of patients receiving treatment within 5-6 days, 38% (6 of
16) survived.
Of patients receiving treatment in 7 or more days, 19% (10
of 44) survived.

Examining mortality in total, 81% of all infected patients (103 cases)
died. The median hospitalization time for these patients was six days.
Mortality was lower in cases that were clustered together rather than
primary, stand-alone cases. For secondary cases, due to clusters, the
median treatment time was five days instead of seven. Mortality was
higher in cases that resided in urban areas or from indirect exposure
to infected poultry through an intermediate.



The authors conclude that improving treatment times can help improve
outcomes for bird flu cases.В "Early case identification and
treatment with oseltamivir is key to addressing the high case-fatality
rate in Indonesian cases. There is a clear need to identify definite
causes for high-case fatality...While additional research is done we
propose the following strategies to provide early diagnosis and prompt
treatment to improve quality of case management. Poultry surveillance
is being stepped up, and active human case finding by local health
centres and village officials is being instituted in areas of poultry
deaths." Additionally, they point out, investigations in the
surveillance system should include any history of contact with poultry,
especially dead and sick poultry, for all illness similar to influenza.
They add: ""This strategy will promote earlier and targeted detection
of patients that have clear exposure to diseased birds, which should
then prompt earlier treatment and reduced case fatality. Finally, all
health-care workers should be trained in case management of early H5N1
influenza, and should be equipped with oseltamivir to enable timely
administration."



Prof. Sheila Bird, Medical Research Council (MRC) Biostatistics Unit,
Cambridge, UK, and Jeremy Farrar, Professor of Tropical Medicine,
Oxford University, contributed an accompanying comment in which they
emphasize the importance of early preventative action. "Consideration
needs to be given now - not in the teeth of a pandemic, and not deflected
by either proprietary defensiveness or opportunistic profiteering - to
gauging the comprehensiveness of national surveillance for human H5N1
cases. And to ensuring the analysability of a minimum dataset on the
exposures and clinical course of every confirmed case of human H5N1.
The world also needs to find a more equitable way to ensure that all
share in the benefits of such important research. Indonesia could give
the lead here."



Factors associated with case fatality of human H5N1 virus
infections in Indonesia: a case series

I Nyoman Kandun, Erna Tresnaningsih, Wilfried H Purba, Vernon Lee, Gina
Samaan, Syahrial Harun, Eka Soni, Chita Septiawati, Tetty Setiawati,
Elvieda Sariwati, Toni Wandra

highest case-fatality rates worldwide. We described the factors
associated with H5N1 case-fatality in Indonesia.

Lancet Online August 14, 2008

DOI:10.1016/S0140-6736(08)61125-3

Click Here For Journal



Minimum dataset needed for confirmed human H5N1 cases

Sheila M Bird, Jeremy Farrar

Lancet Online, August 14, 2008

DOI:10.1016/S0140-6736(08)61126-5

Click Here For Journal




Written by Anna Sophia McKennety