CLUSTER IN INDONESIA

Avian influenza – situation in Indonesia – update 12

18 May 2006

The Ministry of Health in Indonesia has confirmed an additional seven cases of human infection with the H5N1 avian influenza virus. Six of the cases were fatal.

One fatal case, in a 38-year-old woman, occurred in the city of Surabaya, in East Java. She developed symptoms on 2 May, was hospitalized on 7 May, and died on 12 May. The case is the first reported from this area.

The remaining six cases are from the village of Kubu Sembelang in the Karo district of North Sumatra. All six are members of an extended family, and all but one lived in neighbouring houses.

Associated with the Kubu Sembelang outbreak is a seventh family member, a 37-year-old woman. She developed symptoms on 27 April and died of respiratory disease on 4 May. No specimens were obtained before her burial, and the cause of her death cannot be confirmed. She is, however, considered the initial case in this family cluster.

The six confirmed cases in Sumatra include the woman’s two sons, aged 15 and 17 years, who died respectively on 9 May and 12 May. The 28-year-old sister of the initial case died on 10 May. This sister had an 18-month-old girl, who died on 14 May. The fifth confirmed case, who is still alive, is the 25-year-old brother of the initial case. The sixth confirmed case is the 10-year-old nephew of the initial case. He died on 13 May.

One additional family member, who had been hospitalized, has subsequently been ruled out based on both negative laboratory results and the absence of clinical symptoms compatible with H5N1 infection.

This is the largest cluster of cases, closely related in time and place, reported to date in any country and is being carefully investigated by Indonesia’s ministries of health and agriculture and by WHO epidemiologists. The source of exposure for the initial case is still under investigation, with exposure to infected poultry or an environment contaminated by their faeces considered the most plausible source.

The likely source of infection for the additional cases has not yet been determined. Multiple hypotheses are being investigated. Apart from living in close proximity to each other, the cases in this cluster are known to have participated in a family gathering around 29 April. The cases may have acquired their infection from a shared environmental exposure yet to be identified. The possibility of limited human-to-human transmission cannot be ruled out at present.

Investigators at the outbreak site have found no evidence that infection has spread beyond members of this single extended family. No influenza-like illness has been identified in health care workers or other persons in close contact with the patients. If human-to-human transmission has occurred, it has not been either efficient or sustained.

The newly confirmed cases bring the total in Indonesia to 40. Of these cases, 31 have been fatal.

THE WASHINGTON POST

She also revealed that the government had not set aside any money this year to vaccinate poultry against the virus, though officials had trumpeted this as the centerpiece of their strategy to contain the disease.

Naipospos repeated her allegations late last month, but this time in Indonesian in an interview with the influential local newspaper Kompas.

A day after the article was published, the Agriculture Ministry fired her.

UN officials complained that her dismissal has set back efforts to fight the virus, faulting the government for ousting what they call its most respected animal health expert at the height of a crisis.

Naipospos alleged that bird flu has never been a priority in the Agriculture Ministry. "They could not see the potential threat until there was an actual threat," she said in an interview with The Post last week. "I talked to the minister about it many times. He said a disease outbreak is not a national emergency, not a disaster."

Agriculture Minister Anton Apriyantono said the Indonesian government considers bird flu a matter of great concern. Every morning, he said, he files a report with President Susilo Bambang Yudhoyono on efforts to battle the disease.

"That means our attention is very high on how to address this problem," the minister said during an interview in his office.

Apriyantono said he fired Naipospos because he was not happy with her handling of bird flu and her working relationship with top ministry officials.

When the virus first appeared in Indonesia in the summer of 2003, government officials were divided over whether the sudden death of hens on a commercial farm on Java island was caused by bird flu or a less virulent ailment, Newcastle disease.

Nidom, a professor at Indonesia's Airlangga University, was called in. Within two months, he said his laboratory research had determined that the ailment was indeed bird flu, and was genetically related to a strain found seven years earlier in southern China.

But the owners of major poultry companies, who have personal ties to senior Agriculture Ministry officials, insisted that any containment efforts be done secretly, Naipospos recalled.

These eight farming conglomerates, which handle 60 percent of the country's poultry, feared that publicity would harm sales of chicken and eggs. Offering new details in her interview last week, Naipospos said owners even lobbied Indonesia's president at the time, Megawati Sukarnoputri.

In late January 2004, Nidom broke ranks and announced his findings to the Indonesian media. A day later, the Agriculture Ministry confirmed the bird flu outbreak. But the disease had already spread across Java and on to Bali and Sumatra islands.

"It was too late. The virus was everywhere," Nidom recalled.

Last fall, with human cases mounting in Vietnam and Thailand, Nidom was growing increasingly nervous about the prospect of the epidemic spreading to Indonesians.

Shortly before its scheduled start, a senior agriculture official contacted the head of Nidom's institute and demanded that foreign participants and all media be banned, according to Yoes Prijatna Dachlan, chairman of the university's Tropical Disease Center. Dachlan rejected the conditions and canceled the gathering.

Apriyantono said in the interview that he was unfamiliar with the incident, but that Indonesia was open to foreign researchers. Through this summer, avian flu continued to spread, often unreported, and containment efforts remained unfunded.

Responding to public anxiety, Apriyantono went on television to oversee the culling of several dozen pigs and ducks on a farm 15 kilometers away.

But when the cameras left, the campaign stalled. Officials backed away from a vow to kill about 200 swine in the immediate area. Thousands of chickens, identified by health experts as the leading suspects in the outbreak, escaped slaughter.

As suspected human cases mounted last month, government officials said they would take extraordinary measures. Apriyantono announced that he was changing course and would order a mass slaughter of poultry in any area declared highly infected.

But, one month later, Apriyantono acknowledged that he had yet to define such an area. As a result, he has now directed that culling be limited to the specific property where an infection is detected and that neighboring birds be spared.

THE WASHINGTON POST

Information received on 23 May 2005 from Prof. H.R. Wasito, Director General of Livestock Services, Department of Agriculture, Jakarta:

End of previous report period: 6 April 2005 (see Disease Information, 18 [14], 102, dated 8 April 2005).

End of this report period: 23 May 2005.

Precise identification of agent : highly pathogenic avian influenza virus subtype H5N1.

Three surveys were conducted in Tangerang district, Banten province, using purposive and pooled sampling. A total of 187 samples were taken during the surveys.

- The first survey was conducted on 23 February 2005 in a farm in Babat village, Legok subdistrict, where 5 out of 10 nasal swabs were positive and the subtype involved was identified as H5N1.

- As a follow-up, the second survey was conducted on 14 April 2005 in Rancaiyuh village, Panongan subdistrict, where 6 out of 10 nasal swabs taken from 31 pigs over 5 months old were positive for H5N1.

- The third survey was on 26 April 2005 in Babat village, Legok subdistrict, where 1 out of 6 nasal swabs taken from 6 pigs over 1 year old was positive for H5N1.

Not a single pig has shown clinical signs of avian infuenza.

Details of outbreaks:

(1) West Java

* infected animals without clinical signs

Diagnosis:

Further investigations have been made in seven provinces (Central Java, West Java, West Kalimantan, South Sulawesi, Bali, Riau and North Sumatra). The results of the serological testing of 250 samples (sera and swabs) were all negative.

Source of outbreaks or origin of infection: these pig farms are adjacent to backyard chicken farms. The infection in pigs was due to contamination with chicken manure.

Control measures

A. Undertaken:

- quarantine;

- movement control inside the country;

- disinfection of infected premises/establishment(s).

B. To be undertaken: partial stamping out.

Treatment of affected animals: no.

Vaccination prohibited: no