june 2 ai situation pwrpoint 29 5 06

8/12/2019 June 2 AI Situation PwrPoint 29 5 06

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World ealth Organization

Cumulative Number of Confirmed Human Cases of AvianInfluenza A/(H5N1) Reported to WHO globally

(as of 29 May 2006)

Country 2003 2004 2005 2006 Total

cases deaths cases deaths cases deaths cases deaths cases deaths

Azerbaijan 0 0 0 0 0 0 8 5 8 5

Cambodia 0 0 0 0 4 4 2 2 6 6

China 0 0 0 0 8 5 10 7 18 12

Djibouti 0 0 0 0 0 0 1 0 1 0

Egypt 0 0 0 0 0 0 14 6 14 6

Indonesia 0 0 0 0 17 11 31 25 48 36

Iraq 0 0 0 0 0 0 2 2 2 2

Thailand 0 0 17 12 5 2 0 0 22 14

Turkey 0 0 0 0 0 0 12 4 12 4

Viet Nam 3 3 29 20 61 19 0 0 93 42

Total 3 3 46 32 95 41 80 51 224 127


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Human Cases H5N1, Location(as of 29/5/06)


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

by week

0

1

2

3

4

5

6

7

8

9

10

11

0 7 / 0 3 / 2 0 0 5

1 7 / 7 / 2 0 0 5

3 1 / 7 / 2 0 0 5

1 4 / 8 / 2 0 0 5

2 8 / 8 / 2 0 0 5

0 9 / 1 1 / 2 0 0 5

2 5 / 0 9 / 2 0 0 5

1 0 / 0 9 / 2 0 0 5

2 3 / 1 0 / 2 0 0 5

1 1 / 0 6 / 2 0 0 5

2 0 / 1 1 / 2 0 0 5

1 2 / 0 4 / 2 0 0 5

1 8 / 1 2 / 2 0 0 5

0 1 / 0 1 / 2 0 0 6

1 5 / 1 / 2 0 0 6

2 9 / 1 / 2 0 0 6

0 2 / 1 2 / 2 0 0 6

2 6 / 2 / 2 0 0 6

0 3 / 1 2 / 2 0 0 6

2 6 / 3 / 2 0 0 6

0 4 / 0 9 / 2 0 0 6

2 3 / 4 / 2 0 0 6

0 5 / 0 7 / 2 0 0 6

2 1 / 5 / 2 0 0 6

Week Ending

C a s e Pending

Recover Fatal


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

0

2

4

6

8

10

12

14

16

J u l i

A u g u

s t

S e p t e

m b e r

O c t o b

e r

N o v e m

b e r

D e c e

m b e r

J a n u

a r i

F e b r u

a r y M a

r c h A p r i l

M a y

Month

C a s e Recover

Fatal


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Cases by urban/ruralEnvironmental Setting

1327%

2144%

1429%

Urban setting

Rural setting

Semi-urban setting

UrbanSemi-urban

Rural


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Cases by age group and sex

-8 -6 -4 -2 0 2 4 6 8

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 45

A g

Male | Female

MaleFemale


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Cases by occupation

Child11

22%

Student10

20%

Poultry Worker /

Breeder 48%

Wet Market Worker 2

4%

HCW1

2%

Non-farm Occupation14

30%

Agricultural Farmer 1

2%

Uncertain6

12%

ChildStudentPoultry Worker / Breeder Wet Market Worker HCWNon-farm Occupation

Agricultural Farmer Uncertain


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Likely Source of Exposure

1123%

1735%

24%

613%

1225%

Direct ExposureIndirect ExposureFertiliser InconclusivePending

Direct

Indirect

Pending

Inconclusive


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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


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Duration of Illness (fatal cases, n= 36)

0

2

4

6

8

10

12

Jul-Sep 05 Sep-Dec 05 Jan-Mar 06 Apr-Jun 06

Yearly Quarter

D u r a

t i o n

( D

a


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Clusters in IndonesiaCluster Cases Fatal Source H2H Type of cluster

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

3 Inconclusive Cannot be ruledout

Blood-relatedfamily

2 2 (2 confirmed) 1 Fertilizer Cannot be ruledout

Blood-relatedfamily

3 3 (3 confirmed) 0 Direct (sickchicken)

Unlikely Blood-relatedfamily

4 2 (2 confirmed) 1 Exposure(sickchicken)


5 4 (2 confirmed, 2suspect)

2 Direct (sickchicken)


6 8 (7 confirmed, 1suspect)

7 Pending Cannot be ruledout

Blood-relatedfamily


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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


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Serious problems

52% (25) of human cases are sentinel casesfor 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.


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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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Days Between Onset-Hospitalization-Death

0 2 4 6 8 10 12 14 16 18 20

123456789

101112131415161718192021222324252627282930313233343536373839404142434445464748

C a s e

N

Days

Days between Onset-HospitalizationDays between Hospitalization-Death


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

Number of cases

3 5 7

1 2 4 6 822 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

alive died lab-confirmed

April May

5 cases diagnosed at KJ hospital,referred to Medan

Medan Provincial Health Office notifiesMOH, MOH notifies WHO

MOH/WHO team in Medan to interviewsurvivors and family

Rule out of HCW andfamily member

Lab confirmation of 5 casesInterviews Kabenjahe, local

investigation Kubu

Village investigation


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Serious problems

Decentralisation Lack of chain of command. Lack of authority.

Inadequate budget allocations. Lack of political will?

Long time line for action.


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Thank You


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Acknowledgements Investigation Teams

Health/Ag Officials Lab Workers

Hospitals Consultants


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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?


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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 samplesalso 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


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Lessons Learnt

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


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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 andother 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.


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If cases are missed Cases reported % under-

reportingEstimated no. of

cases50 10% 55

50 50% 50

50 90% 500

50 99% 5000


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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


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CHAIRMAN

AI in Human Control Group Research and

Development GroupVaccine and

Anti-Viral Group AI in Animal Group

Communication and PublicInformation Sub-group

Operation Officer

BudgetPlanning International Cooperation

Secretariat

Provincial AI Control Committee

District AI Control Committee

NATIONAL COMMITTEE ON AVIAN INFLUENZA CONTROL - KOMNAS


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MoAg / FAO

Strategic Work Plan developed in Dec2005. Surveillance Selective culling Vaccination


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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


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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 rollingout guidelines for health centers on the management of suspectedcases of AI.

Last Revised


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AI Cluster Outbreak, Kubu Simbelang, May 200655yo F

JMother of Index +4 sibsNo illness/Live House 1

37yo FPBG

Onset: 24/4Died: 4/5

29yo FABS

Onset: 5/5Died: 10/5 PCR+

??yo MEr

No illness

32yo MD


25yo MJG

Onset: 4/5Survivor PCR+

18yo SonRKK


17yo SonBKK


10yo SonA

No illness

1-1/2yo DaughterBbT


10yo SonC

No illness

6yo DaughterM

No illness

21yo DaughterF

No illnessLiving House 1

29yo WifeB

No illness

32yo HusbandH

No illness

10yo SonRG


6yo Son

No illness

??yo WifeAm

No illness

House 1 / Index House 3 House 4

3yo SonP

No illness

5mo SonP

No illness

Legend :

Blue = male Peach= female

Solid = No illness Vert.stripe = death Horiz.stripe = survivor

House 2

2?yo FianceI

No illness

25 May 2006

(DifferentVillage)


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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

Dra. Nasirah B

Ses.Dit.Gen

Drs. Abdul Muchid

Dit. Comm Pharm.& Clinic

Dr. Husniah Rubiana

Dit. Rational UseOf Drugs

Drs. Bahron Arifin

Dit. Public Drugs &Health Supply

Drs. Tato Suprapto

Dit. Prod & Distrib.Of Med Devices

Drs. Zulkarnain Kasim

Secretary PPSDM

Dr. Triono Sundoro

Chief Pusdiklat

Dr. Setiawan Soeparan

Chief Pusdiknakes

Dr. Untung SusenoChief Pusgunakes

Dr. Asjikin Iman Hidayat

Chief Empowerment ofHealth Manpower

Dr. Bambang Hartono

Ses.Dit.Gen

Dr. Sri Hermiyanti

Dit. Family Health

Dr. Wandaningsih

Dit. Komunitas

Dr. Pandu SetiawanDit. Mental Health

Dr. Rachmi Untoro

Dit. Nutrition

Drs. Ida Bagus Indra G

Dit JPKM

Dr. Rustam S Pakaya

Ses.Dit.Gen

Dr. Ratna Rosita

Dit. Med Care & BasicDental Care

Dr.

Dit. Med Care & Spe-cialistic Dental Care

Drg. Haerawan

Dit. Nursing & TechnicalMedic

Ir. Tugiyono

Dit. Medical Facilities& Equipment

Dr. Yulizar Darwis

Dit. Health Laboratory

Dr. Indriyono Tantoro

Ses.Dit.Gen

Dr. Rosmini Day

Dit. Direct CDC & EH

DR.Dr.Hariadi Wibisono

Dit. Vector Borne DC

Dr. Yusharmen Harun

Dit. Epid. Surveillance& Matra Health

Dr. Wan Alkadri

Dit. Env. Health

Dr. Achmad Hardiman

Dit. NCDC

Drg. Titte Kabul

Secretary NIHRD

Dr. Suwandi Makmur

Chief, Center for HealthService & Personnel

Dr. Erna Tresnaningsih

Chief, Research Dev.On CDC

Dr. Faizati Karim

Chief, Research DevOn Health Ecology

Dra. Nani Sukasediati

Chief, Center for Pharm.& Traditional Drugs

Mr. Soenarno Ranu W

Chief, Center forNutrition & Food

ORGANIZATIONAL STRUCTUREMINISTRY OF HEALTH REPUBLIC OF INDONESIA

june 2 ai situation pwrpoint 29 5 06

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