A report from the front lines

Andrew Jeremijenko – at 02:47

In response to NS1 my plan when I came overseas was to be here for only 3 months. After 8 years in Asia I am ready to go home. I should not be commenting on the pandemic virus. It is surreal. I am a medical doctor with a Masters of Epidemiology degree. There should be a Professor here with multiple publications on influenza making comments. The truth is apart from the authors from NAMRU2 and their collaborators, there are virtually no scientists here who have published about influenza in Indonesia. This is a reflection of current level of skill on the ground. It needs to be improved. We need these influenza experts to do the studies that have been suggested on Fluwikie and the scientists need to be funded and given the freedom to do those studies and not be obstructed. This is an urgent situation.

Dr Nidom’s hypothesis about asymptomatic cases in humans does need to be studied, I think it unlikely but it should be proven. There have certainly been a number of mild cases found during investigations, and it is quite possible we may have missed mild cases. With 2000 deaths a day from acute respiratory infections we could be missing many severe cases as well. These questions need to be researched.

It is important to look at the bigger picture some time. The health statistics of Indonesia show Indonesia has performed poorly in areas such as infant mortality rate when compared to its neighbours like Thailand, Malaysia and Singapore. If you read the WHO health report 2000, health care systems, or WHO health report 2006, working together for health you can see that the health system is poorly resourced and understaffed.If you read these reports you will also realize the depth of problems in places like Africa.

I sometimes feel if millions of deaths from TB, malaria and other infectious diseases hasn’t made them change their policies why would bird flu. Indonesia continues to lock out foreign doctors and hence many wealthy people travel overseas for medical care. Even after a disaster like the tsunami they got rid of all the foreign medical teams within 3 months, 26/3/05 - 2 days before a second large earthquake occurred in Nias 28/3/05. Now they are calling for the foreigners to leave Jogja, even as the Merapi volcano gets ready to explode.

I believe the medical closed door policy is an attempt by rich doctors to protect their own market (mainly in Jakarta). This is in stark contrast to the rest of the world that are importing doctors from all over the world to help with health. Indonesia has ignored its own people cry for health care. If Indonesia opened its doors today, I believe doctors would chose other countries. They have set their country back years in health care because of their policies. They get offended when foreign doctors and scientists feel the urge to tell them the system needs to be improved.

A number of people in Indonesia are upset about my comments in the Nature article http://declanbutler.info/blog/?p=41. All I am pointing out as WHO does in their reports is that the systems here are not good and it will be difficult to contain a pandemic, but that we must try.

I do not think that the pandemic virus is here, but Indonesia is not handling this bird flu situation effectively and the proof is in the continuing human cases. They are not controlling the disease in birds and they are getting more human clusters and larger clusters such as the one in Medan. Unlike other countries that jump on the problem and fix it eg Turkey and even ones that have taken longer to control the disease like Vietnam and Thailand, Indonesia puts on a media face tries to calm people down and does not address the underlying problems.

The problems continue A. They have been ineffective at controlling the disease in birds and in treating and investigating the human cases. They have the highest rate of new cases in the world and the worst death rate. In comparison to other countries Indonesia should be chastised for its poor efforts. B. Their investigations are failing to identify the cause. They are so delayed that the virus has often disappeared from the environment. The are disjointed, ineffective and not available for peer or public review. There have been 50 cases and no virus betwen humans and animals has ben matched except maybe the cat in Indramayu and a bird from 2 years before in Medan. C. The delays in investigation have onflow effect - slow diagnosis, poor treatment, poor infection control and high case fatality rates. D. They were unable to demonstrate an ability to contain the virus in this last cluster, with many patients being discharged or absconding to cough all over the commmunity and later coming back to the hospital to die. E. They continue to delay and obstruct international investigators from doing their job. The onset of first case was 25th April but the CDC investigator did not get invited up to investigate this cluster until 16th May. They continue not to invite NAMRU2 on investigations F. Their surveillance is limited. There are 2000 deaths a day from pneumonia and 300 deaths a day from TB. Most of these deaths are in people who have been exposed to chickens. With the virus endemic in Indonesia basically all of these should be suspect cases. Very few are tested, I don’t think we have ever tested more then 10 suspect H5N1 cases a day. There are a number of family clusters I am aware of that have never been tested or where only one person was tested. Only limited testing in large cities like Surabaya, Medan, Bandung and Jakarta occurs. We know we are missing cases especially in rural areas. We don’t know how many. G. To date there has still been no autopsies. Many suspect cases that I think were human H5N1 cases, were not able to be diagnosed as we could not get lung samples from the patients. Because of cultural and religious beliefs people/officials do not push for this despite potential to confirm diagnosis and the importance of knowing the pathology in human cases. H. Sampling is inadequate. Many people die before samples are taken especially in remote areas. We don’t know how long people are infectious in Indonesia because if they do sample they don’t follow protocols such as serial sampling, e.g. sample every second day for 2 weeks. We do not yet know if the infectious period is 5 days or 14 days or longer. Once the diagnosis is made it is rare for sampling to continue and with the high fatality rate in the hospitals many die, so we only know they were probably infectious until death. To my knowledge few stool tests to see if the virus is excreted in the stools have been done. If you asked me if virus is excreted in the stool, my answer is I don’t know. I. Do pigs or cats play a role in infection. As no systematic surveillance has been done in other animals, once again we don’t know. J. The chance for a pandemic mutation in the virus in Indonesia continues to be high as they continue to have the most cases and most deaths this year. There are a lot of things that we don’t know.

I do not think there is need to panic, but there is need to encourage improvements. I have lived in Indonesia for a long time, if people keep smoothing it over, then nothing gets done here. There has to be a lot of upset and urgency before Indonesia actually gets it off the we’ll get to that eventually list. I understand they have a host of problems to deal with, but this one is not one that we should allow them to ignore.

If the international and national outrage at the poor management of bird flu is not expressed, we will find that this disease will continue on its path in Indonesia towards a pandemic virus and control measures proven to be effective in other countries will not be implemented. All the best Andrew