Human influenza A H5N1 in Indonesia: health care service-associated delays in treatment initiation

Abstract

BackgroundIndonesia has had more recorded human cases of influenza A H5N1 than any other country, with one of the world’s highest case fatality rates. Understanding barriers to treatment may help ensure life-saving influenza-specific treatment is provided early enough to meaningfully improve clinical outcomes.MethodsData for this observational study of humans infected with influenza A H5N1 were obtained primarily from Ministry of Health, Provincial and District Health Office clinical records. Data included time from symptom onset to presentation for medical care, source of medical care provided, influenza virology, time to initiation of influenza-specific treatment with antiviral drugs, and survival.ResultsData on 124 human cases of virologically confirmed avian influenza were collected between September 2005 and December 2010, representing 73% of all reported Indonesia cases. The median time from health service presentation to antiviral drug initiation was 7.0 days. Time to viral testing was highly correlated with starting antiviral treatment (p < 0.0001). We found substantial variability in the time to viral testing (p = 0.04) by type of medical care provider. Antivirals were started promptly after diagnosis (median 0 days).ConclusionsDelays in the delivery of appropriate care to human cases of avian influenza H5N1 in Indonesia appear related to delays in diagnosis rather than presentation to health care settings. Either cases are not suspected of being H5N1 cases until nearly one week after presenting for medical care, or viral testing and/or antiviral treatment is not available where patients are presenting for care. Health system delays have increased since 2007.

Emerging respiratory tract viral infections

“…Full viral genome analysis of the fatal case in Canada has shown an HA gene of clade 2.3.2.1c and is a reassortant with an A(H9N2) subtype lineage polymerase basic 2 gene without mutations conferring resistance to adamantanes or neuraminidase inhibitors (NAIs) [10]. Delay in the delivery of appropriate treatment to patients with influenza A(H5N1) infection in Indonesia was mainly related to delay in diagnosis rather than late presentation to healthcare settings [16]. Delay in the delivery of appropriate treatment to patients with influenza A(H5N1) infection in Indonesia was mainly related to delay in diagnosis rather than late presentation to healthcare settings [16].…”

Recognizing true H5N1 infections in humans during confirmed outbreaks

“…Examination of the times from symptom onset to various interventions reveals that in an outbreak, cases that present early in the outbreak's course are unlikely to be immediately recognized, and are consequently disadvantaged by delays in diagnosis and initiation of appropriate antiviral therapy, with the lack of clinical differentiators to signal true H5N1 infection further compounding the difficulties clinicians face [12]. It is evident that oseltamivir confers a survival benefit for true cases of H5N1, and when confronted with cases with influenza-like symptoms during an outbreak and in the absence of immediate virological testing, clinicians should seriously consider initiating antiviral treatment as soon as possible.…”

Pathogenic viruses: Molecular detection and characterization

“…Southeast Asia is considered to be especially vulnerable to potential outbreaks of pathogenic viruses and a number of pathogenic viruses have been reported to circulate in this region. These include Nipah virus (NiV) (Looi and Chua, 2007), H5N1 (Adisasmito et al, 2013), Dengue virus (Sasmono et al, 2015;Dhenni et al, 2018), Rabies virus (Susilawathi et al, 2012), West Nile virus , Chikungunya virus (Kosasih et al, 2013;Riswari et al, 2016), Zika virus , Coxsackievirus virus (Wiyatno et al, 2016), Measles virus (Hartoyo et al, 2017), Rhinovirus C (Wiyatno et al, 2018), Japanese encephalitis virus (Gao et al, 2013), Seoul virus (Hofmann et al, 2018) etc. The 2019 novel coronavirus (2019-nCoV) which emerged in Wuhan, Hubei, China, has also been identified in this region (Huang et al, 2020).…”