6 June 2006

 

Avian influenza - human cases in Indonesia

The Ministry of Health in Indonesia has confirmed seven cases of human avian influenza [1,2]. One case is associated with the recently reported family cluster in Kubu Simbelang village in the Karo District of North Sumatra [3]; the remaining six cases are not associated with this family cluster and are widely dispersed geographically.

The case associated with the family cluster is the brother of the initial case [1]. Before the onset of his symptoms he was closely involved with caring for his 10 year old son who died of H5N1 infection on 13 May. This contact is considered a possible source of his infection.

The family cluster involves an initial unconfirmed case and seven laboratory confirmed cases [1, 3]. All are members of an extended family who resided in four households. Each confirmed case in the cluster can be directly linked to close and prolonged exposure to a patient during a phase of severe illness.

Indonesian health authorities and the World Health Organization (WHO) are investigating this cluster and as of 31 May 2006, 54 surviving family members and other close contacts of cases had been identified and placed under voluntary home quarantine [4]. All of these persons, with the exception of pregnant women and infants, are receiving the antiviral drug oseltamivir for prophylactic purposes. Public health teams are also visiting daily to check for symptoms. In addition, active house-to-house surveillance for influenza-like illness is being conducted throughout the village which has around 400 households. To date, no new cases suggestive of H5N1 infection have been detected, indicating that there has been no spread beyond members of this single extended family.

Genetic sequencing of the viruses isolated in this cluster has found no evidence of genetic re-assortment and no evidence of significant mutations. The viruses were found to be genetically similar to those isolated from poultry in North Sumatra during a previous outbreak [1].

Continued close monitoring of the situation in Kubu Sembelang will be continued for three weeks following 22 May, the date the last known case in the cluster died.

This cluster has not led to a change in the WHO influenza pandemic alert, which remains at level three [4]. There is no evidence that H5N1 influenza A virus is spreading in an efficient and sustained manner from person to person.

The remaining six cases are not associated with this family cluster and are widely dispersed geographically [2]. They include:

An 18 year old man from East Java who developed symptoms on 6 May and is now recovering. He is known to have had contact with dead chickens in the week prior to the onset of his symptoms.

A 10 year old girl and her 18 year old brother from Bandung, West Java. Both developed symptoms on 16 May and died in hospital on 23 May. They had a history of contact with sick poultry in the week before symptom onset.

A 39 year old man from West Jakarta who developed symptoms on 9 May and died in hospital on 19 May. He is known to have cleaned pigeon faeces from a blocked roof gutter at his home shortly before symptom onset.

A 43 year old man from South Jakarta who developed symptoms on 6 May and has now recovered.

A 15 year old girl from West Sumatra who developed symptoms on 17 May and is currently hospitalised.

A map showing the location of the family cluster and these other six cases can be found at the following link: http://www.who.int/csr/don/IDmap.jpg  

Global Case Totals

The global total of laboratory-confirmed cases reported by the WHO as of 29 May 2006, is in the table below, and can be found on the WHO website at: http://www.who.int/csr/disease/avian_influenza/country/cases_ta

ble_2006_05_29/en/index.html

COUNTRY	HUMAN CASES as of 29 May 2006					DEATHS
	2003	2004	2005	2006	TOTAL
Azerbaijan	0	0	0	8	8	5
Cambodia	0	0	4	2	6	6
China	0	0	8	10	18	12
Djibouti	0	0	0	1	1	0
Egypt	0	0	0	14	14	6
Indonesia	0	0	17	31	48	36
Iraq	0	0	0	2	2	2
Thailand	0	17	5	0	22	14
Turkey	0	0	0	12	12	4
Viet Nam	3	29	61	0	93	42
TOTALS	3	46	95	80	224	127

Advice for travellers

Examination of previous human cases of avian influenza has indicated that the greatest risk for transmission from birds to humans comes when there is close human contact with domestic poultry. This is particularly so in settings of diseased household flocks and when there has been slaughtering, defeathering, and preparation of poultry for consumption. No cases have been linked to consumption of properly cooked meat or eggs.

There remain no restrictions for travel to countries with avian influenza. Nevertheless, travellers should exercise precautions [5].

The Health Protection Agency (HPA), Centre for Infections has published an algorithm for the management of travellers or visitors arriving from countries (or areas within countries) affected by avian influenza [6]. These regions are revised as new information is provided from the WHO and the World Organisation for Animal Health (OIE) on detection of avian influenza.

The HPA algorithm provides guidance on the recognition, investigation and management of persons with fever or history of fever and respiratory symptoms, and who have had an exposure to persons or birds with suspected avian influenza within seven days of their arrival in the UK. Physicians who see persons whom they suspect may have avian influenza, should evaluate them according to this algorithm.

References

1. World Health Organization. Avian influenza - situation in Indonesia - update 14. 23 May 2006 [cited 5 June 2006] Available online at http://www.who.int/csr/don/2006_05_23/en/index.html

2. World Health Organization. Avian influenza - situation in Indonesia - update 15. 29 May 2006 [cited 5 June 2006] Available online at http://www.who.int/csr/don/2006_05_29/en/index.html

3. World Health Organization. Avian influenza - situation in Indonesia - update 12. 18 May 2006 [cited 23 May 2006] Available online at http://www.who.int/csr/don/2006_05_18b/en/index.html

4. World Health Organization. Avian influenza - situation in Indonesia - update 16. 31 May 2006 [cited 5 June 2006] Available online at http://www.who.int/csr/don/2006_05_31/en/index.html

5. NaTHNaC. Avian influenza - advice for travellers to affected areas. 7 April 2006. [cited 5 June 2006] Available online at http://www.NaTHNaC.org/pro/clinical_updates/avianinfluenza_trave

ladvice_070406.htm

6. Health Protection Agency. Algorithm for the management of returning travellers and visitors from countries affected by avian influenza (H5N1) presenting with a febrile respiratory illness: recognition, investigation and initial management. 30 May 2006 [cited 5 June 2006] Available online at http://www.hpa.org.uk/web/HPAweb&HPA

webStandard/HPAweb_C/1195733851442