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Clin Infect Dis. (2011) doi: 10.1093/cid/cir740
Risk Factors for Cluster Outbreaks of Avian Influenza A H5N1 Infection, Indonesia
Tjandra Y. Aditama1,a,
Gina Samaan2,a,
Rita Kusriastuti1,
Wilfried H. Purba1,
Misriyah1,
Hari Santoso1,
Arie Bratasena1,
Anas Maruf1,
Elvieda Sariwati1,
Vivi Setiawaty3,
Alex R. Cook4,
Mark S. Clements2,5,
Kamalini Lokuge2,
Paul M. Kelly2,6, and
I. Nyoman Kandun1
1Directorate-General Disease Control and Environmental Health, Ministry of Health, Jakarta, Indonesia
2National Centre for Epidemiology and Population Health, College of Medicine, Biology, and Environment, The Australian National University, Canberra
3National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
4Department of Statistics and Applied Probability, National University Singapore
5Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
6Population Health Division, Australian Capital Territory Government Health Directorate, Canberra
Correspondence: Gina Samaan, MAppEpid, National Centre for Epidemiology and Population Health, College of Medicine, Biology, and Environment, The Australian National University, Canberra, ACT 0200, Australia (ginasamaan{at}yahoo.com).
Abstract
Background. By 30 July 2009, Indonesia had reported 139 outbreaks of avian influenza (AI) H5N1 infection in humans. Risk factors for case clustering remain largely unknown. This study assesses risk factors for cluster outbreaks and for secondary case infection.
Methods. The 113 sporadic and 26 cluster outbreaks were compared on household and individual level variables. Variables assessed include those never reported previously, including household size and genealogical relationships between cases and their contacts.
Results. Cluster outbreaks had larger households and more blood-related contacts, especially first-degree relatives, compared with sporadic case outbreaks. Risk factors for cluster outbreaks were the number of first-degree blood-relatives to the index case (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI]: 1.20?1.86) and index cases having direct exposure to sources of AI H5N1 virus (aOR, 3.20; 95% CI: 1.15?8.90). Risk factors for secondary case infection were being aged between 5 and 17 years (aOR, 8.32; 95% CI: 1.72?40.25), or 18 and 30 years (aOR, 6.04; 95% CI: 1.21?30.08), having direct exposure to sources of AI H5N1 virus (aOR, 3.48; 95% CI: 1.28?9.46), and being a first-degree relative to an index case (aOR, 11.0; 95% CI: 1.43?84.66). Siblings to index cases were 5 times more likely to become secondary cases (OR, 4.72; 95% CI: 1.67?13.35).
Conclusions. The type of exposure and the genealogical relationship between index cases and their contacts impacts the risk of clustering. The study adds evidence that AI H5N1 infection is influenced by, and may even depend on, host genetic susceptibility.
Risk Factors for Cluster Outbreaks of Avian Influenza A H5N1 Infection, Indonesia
Tjandra Y. Aditama1,a,
Gina Samaan2,a,
Rita Kusriastuti1,
Wilfried H. Purba1,
Misriyah1,
Hari Santoso1,
Arie Bratasena1,
Anas Maruf1,
Elvieda Sariwati1,
Vivi Setiawaty3,
Alex R. Cook4,
Mark S. Clements2,5,
Kamalini Lokuge2,
Paul M. Kelly2,6, and
I. Nyoman Kandun1
1Directorate-General Disease Control and Environmental Health, Ministry of Health, Jakarta, Indonesia
2National Centre for Epidemiology and Population Health, College of Medicine, Biology, and Environment, The Australian National University, Canberra
3National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
4Department of Statistics and Applied Probability, National University Singapore
5Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
6Population Health Division, Australian Capital Territory Government Health Directorate, Canberra
Correspondence: Gina Samaan, MAppEpid, National Centre for Epidemiology and Population Health, College of Medicine, Biology, and Environment, The Australian National University, Canberra, ACT 0200, Australia (ginasamaan{at}yahoo.com).
Abstract
Background. By 30 July 2009, Indonesia had reported 139 outbreaks of avian influenza (AI) H5N1 infection in humans. Risk factors for case clustering remain largely unknown. This study assesses risk factors for cluster outbreaks and for secondary case infection.
Methods. The 113 sporadic and 26 cluster outbreaks were compared on household and individual level variables. Variables assessed include those never reported previously, including household size and genealogical relationships between cases and their contacts.
Results. Cluster outbreaks had larger households and more blood-related contacts, especially first-degree relatives, compared with sporadic case outbreaks. Risk factors for cluster outbreaks were the number of first-degree blood-relatives to the index case (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI]: 1.20?1.86) and index cases having direct exposure to sources of AI H5N1 virus (aOR, 3.20; 95% CI: 1.15?8.90). Risk factors for secondary case infection were being aged between 5 and 17 years (aOR, 8.32; 95% CI: 1.72?40.25), or 18 and 30 years (aOR, 6.04; 95% CI: 1.21?30.08), having direct exposure to sources of AI H5N1 virus (aOR, 3.48; 95% CI: 1.28?9.46), and being a first-degree relative to an index case (aOR, 11.0; 95% CI: 1.43?84.66). Siblings to index cases were 5 times more likely to become secondary cases (OR, 4.72; 95% CI: 1.67?13.35).
Conclusions. The type of exposure and the genealogical relationship between index cases and their contacts impacts the risk of clustering. The study adds evidence that AI H5N1 infection is influenced by, and may even depend on, host genetic susceptibility.
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