Research on avian influenza (including avian influenza situation in Indonesia)- agenda item 3.3

______________________________________________ Thirtieth Session of WHO South-East Asia Advisory Committee on Health Research Jakarta, Indonesia, 14-16 March 2007 SEA/ACHR/30/7 05 March 2007 Agenda Item 3.3 RESEARCH ON AVIAN INFLUENZA (INCLUDING AVIAN INFLUENZA SITUATION IN INDONESIA) CONTENTS 1. Introduction...........................................................................................................1 2. Research on avian influenza in Indonesia ......................................................2 3. Areas for future research ...................................................................................3 1 RESEARCH ON AVIAN INFLUENZA (INCLUDING AVIAN INFLUENZA SITUATION IN INDONESIA) 1. Introduction In Indonesia, the epidemic of avian influenza H5N1 in birds started on the island of Java in August 2003. By 2004, the disease had spread through many provinces in the nation’s archipelago and by the end of 2006 was considered endemic in parts of Java, Sumatra, Kalimantan, Bali, Sulawesi and West Timor. The disease affected all of the poultry sectors; from the industrial production to the backyard poultry sectors. The disease has affected many bird species, including chickens, ducks, quails and songbirds. This is problematic not only due to the potential impact of a new influenza pandemic, but the death of millions of poultry and other birds that has led to a loss of income and protein-supply for many families caring for poultry in the backyard setting. As of February 28, 2007, a total of 81 cases (30% of global total) and 63 deaths (38% of global total). Case fatality rate is 78%. Most important priorities in Indonesia are two-fold: (a) preventing transmission to human beings from poultry and, (b) reducing case fatality rate as much as possible. Good operational research can play an important role in guiding action based on evidence relating to the above two initial priority issues in Indonesia Research on AI would enhance understanding of this rapidly spreading infection and build an evidence base which would help in formulating effective target interventions. The development of a pandemic vaccine has become more difficult because of the divergence of circulating viruses which has distinct genetic and antigenic groups. Results from clinical trials of pandemic vaccines have shown that these vaccines confer little protection across the different genetic groups. 2 Monitoring for virus resistance to antiviral drugs also needs to continue. There is also a possibility that these resistant strains may be replaced by fully susceptible strains as the virus continues to evolve. 2. Research on avian influenza in Indonesia Indonesia, in collaboration with the Netherlands, is conducting seroprevalence studies in poultry farmers and cullers. Hospital records will be examined in a search for retrospective cases of acute respiratory illness. Some 44 hospitals have been included in this study and 8 laboratories have been designated. Testing of suspected human H5N1 infections is performed rapidly in the national laboratory, with parallel confirmatory testing performed in the NAMRU-3 laboratory. Three tests are used in Indonesia: RT-PCR, haemagglutinin inhibition with horse red blood cells as a confirmatory assay, and DNA sequencing. Serosurveys of over 2000 people were conducted and only 1 poultry worker tested positive. A sentinel human influenza surveillance conducted by NAMRU revealed that no H5 was identified through the 20 sentinel health center / hospital sites Bali Study involved 940 human blood samples collected from households in all 9 districts and 3 wet markets in Bali (all avian influenza affected areas). Samples from chicken, duck and pig were also collected. The findings of the study include: 30% households had chicken deaths; no humans tested positive; 7 ducks and 1 chicken tested positive for H5N1in 2 wet markets. Data from the study suggests that the virus is circulating in market places but not in the communities, the disease remains a rare-event in humans despite widespread disease in birds. 3 3. Areas for future research Priority areas for research include better understanding of the mode of transmission, the risk factors for transmission among children, the role of environmental contamination, knowledge, attitude and practice (KAP) among general population on avian influenza, reasons for high case fatality etc. In addition, developing more effective strategies for the human vaccination against epidemic and pandemic influenza; improving diagnosis and control of avian infections; and developing diagnostic tools and vaccines to be used in outbreak management. Studying the epidemiology of avian influenza in humans is required for effective detection and control of the disease. Such studies include analysis of the mode of transmission in humans and communicability along with identification of the risk factors associated with transmission among humans. Laboratory diagnosis will also greatly benefit from research as it will help in optimizing treatment and utilization of a vaccine strain. User-friendly sensitive and specific rapid diagnostic kits are required for H5 diagnosis at the peripheral levels. Virus characterization of influenza subtypes to determine mutation or reassortment will help provide a scientific basis for risk assessment and will support vaccine research. Effective clinical management of avian influenza calls for data on the clinical course of the disease. This would help in early detection and appropriate management. Descriptive analysis of the clinical manifestations among confirmed cases can be employed to improve clinical case definition for surveillance purposes. There is also a need to assess the reasons for case fatality rates being higher in certain provinces/districts than others. A review of the clinical course of the illness will help in determining the natural history of avian influenza. Evaluation of person-to-person transmission requires research studies conducted among clusters of pneumonia cases 4 WHO could work towards supporting research in Indonesia through initiating collaboration among laboratory, epidemiology, and veterinary medicine This requires identification of collaborating centres to conduct research and allocation of resources to develop the required infrastructure. O:\dpmo\2007\30 ACHR\Working Papers\SEA-ACHR-30-7_Workingpaper_5 March 07.doc